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JA\'UAR\ TO JUNE
LONDON
niUTISH MCDICAL ASSOCIATION
TAVISTOCK SQUART W C 1
WALPOLE LEWIN, MS, ERGS
AND
Sir HUGH CAIRNS, KBC., DM, ERGS
(From the Dniston of Surgery Radcliffe Infiriiirn Oxford and the Military Hospital for Head Iiiiiiries ll'hcatley)
It IS now generally accepted that ccrcbrosp nal fluid
(C5F) rhinorrhoca following a head injur> indicates a
dural tear in relation to a fracture invohing the para
nasal sinuses, and that a fascial repair of the torn dura
IS required as an insurance against intracranial infection
in the future Most of the fractures insoKe the frontal
or ethmoid sinuses * In this paper we consider onl> the
relativelj uncommon group in which the hinorrhoca
was due to fracture of the sphenoidal sinus Such frac-
tures are not always detected by radiological cxamina
tion and a full exploration of this region imoKes special
problems of exposure and accessibility It seems that
there are certain clinical characteristics which may lead
to their detection pre operatively
Anatom}
The sphenoidal air sinuses lie in the body of the
sphenoid bone and arc usually asymmetrical and
Fio t — The outline of the sphenoidal sinus (inlcrrupled tine) in
relation to the base of Ihe skull
separated from one another by a bony septum
They vary considerably in size and may extend into
a well marked lateral recess m the great wing of the
•In exceptional circumslances the fracture involves the petrous
bone and ihe C S F passes into the nose by way of the middle
ar and Eustaebian tube (Caims and Lcwin to be published)
I
sphenoid Fig 1 drawn from a necropsy specimen with
the dura intact, shows that the sinus extends forward
into the anterior fossa, and also laterally beneath the
optic foramina The sphenoid sinus may therefore be
implicated by fractures running across the posterior
part of the anterior fossa as well as bv fractures of the
middle fossa The close relationship of the sinus to the
optic nerves and chiasm, to the pituitary body and
laterally to the carotid arteries is apparent And in
front of the optic chiasm and the upper part of the
subjacent pituitary body is the cislerna chiasmatica
which IS continuous on each side yvith the arachnoid
sheath of the optic nerv es
Incidence
In the years 1938-46, at the RadclilTe Infirmary,
Oxford, and the Military Hospital for Head Injuries,
Oxford yve have seen 84 patients yvith cerebrospinal
rhinorrhoca following closed head injury In 11 there
yvas demonstrated at operation or necropsy a dural tear
in relation to a fracture of the sphenoidal sinus Six
of these, howeyer must be excluded from the present
examination because they also had other dural tears in
relation to the frontal or ethmoidal sinuses, and it was
therefore not possible to say with certainty yvhich tear
yyas responsible for the rhinorrhoea
In the other fiye patients the dura yvas tom only over
the sphenoidal sinus and these cases ire examined in
closer detail Three patients underwent a fascal repair
and have remained well since, nearly lour years after
the operation The other two patients died of pneumo
coccal meningitis, both in the days before penicillin
therapy One of these yvas admitted moribund and died
within 24 hours of admission , the other developed
meningitis on the day before operative repair was
proposed, and he died nine days later
Tlie Fracture
The sphenoidal sinus may be fractured in several ways
following head injury
I After a blow directed to the side of the head the
skull breaks in the coronal plane cither through the
4696
finmsii
MroicAL Jot RSAL
- Jan 6 195J SPHLNOIDAL SINUS FRACIURL \vnH RIIINORRHOEA
coroml ■suture which is sphycd or just behind the suture
snd anterior to the parictil eminences The fracture
runs down into each temporal fossa and then across the
middle fossa to insolve the wall of the sphenoidal sinus
at the tubcrculum sellac or in the anterior wall of the
sella turcica (two cases)
2 A head on blow produces i scscrc central frontal
fracture with comminution of both walls of the frontal
'in the dura inaohcd the ethmoidal as well as the
'•plt'^noidal roof In the five cases in which the dural
•sir was limited to the sphenoidal sinus area, the tear
usually only a few millimetres wide and was situ
ated oscr the tubcrculum sellac or the anterior wall of
the Sella turcica It probablj resulted from splinterint
of ihc thin bone in this region
sinuses from which fracture lines run backwards to
involve the ethmoid and occasionally sphenoidal
sinuses In some of these cases there is a large
central block fracture involving the whole paranasal
sinus area of both sides (two cases)
3 The head on blow may be tiken lower down so
that the bony injurj is predominantly facial resulting
in a central block fracture of the maxilla, and in some
cases a fracture of the mandible as well The oserlying
cribriform plate may be commimilcd This is a frac
ture which on routine radiography mas seem to be
entirely extracranial the extent of the d image to the
cribriform plate and sphenoidal sinus may not be fully
appreciated unless special radiographic projections of
the paranasal sinuses arc tal cn through the orbit as
i'ccasimmarulai' iy" iPNicar i<C'nk'>-a'i* iWr,' nui' jlnhreuir
•>nd Dutt (1947) (one case)
4 The abosc are the ways in which the fractures
occurred m our senes In addition it is possible that
there may be discrete fractures of the skull limited to
the roof of the sphenoidal sinus, similar to those which
base been seen on the roof of the ethmoidal cells at
operation and nccrop y (Johnson and Dutt, 1947
Cairns, 1949, Fig 8)
The Dural Tear — This may be extensise, but we have
had to exclude from this senes cases in which the gap
The Ctrcbrospinal Fluid Rhinorrhoca
lllc outst inding feature of these sphenoidal cases is
the tiature of the rhinorrhoca It is characteristically
proflisc In these five patients it was so described, and
••'■'• It should have been so recorded by different dim
cian^ renders what is an essentially qualitative observa
tion ([,c more rehiblc In all pitients the rhinorrhoca
once begun, continued unabated until operition or
dcalli^ in one cisc for six months
Tl>e following case record gives a typical description
of ihc rhinorrhoL i
C<>u ' — fins pilicnt sustained a coronal fracture of the
'•>'•• 11 tin. lcv-1 of the coronal suture following a motor
ae idem CSr rhinorrhoca was present from the
time ,1 jufj ^ note made 15 days fitcr reads This
soldier continues to have profuse C43 F rhinorrhoca when
cicr ],c t up iind leans over lor tin. Iasi few days il
has htcn comine down the left nostril only though hitherto
'• ha, 5 oni times been from the right and sometimes from
•he left ni tril When the piticnl is lying in the dorsal
rccur„i,eni >iosiiion he feels find passing down his naso
phuTmx an I has to swaillow from lime to time Dunng
•he i,c „ niccp ,t tends at times to get into
his I'lrynx ai d he is awakened with fits of coughing some
limes ,,,cfe The patient was sal up this morning and
within a fivv moments w iiery fluid began to dnp from the
left nostril— about a drop
every second or less I col
hetej 4 ml for cxamina
non and then let him he
down 1 thin) the dnp
would have continued in
definitely in the sutinc
position
In one patient (Case 2)
a profuse rhinorrhoca
began one week after the
injury, at the simc time
as pneumococcal men
ingitis niic meningitis
was treated with intra
thecal penicillin, but
showed i marked ten
deiicv to relapse The
C S r escaping from the
nose contained a con
sidcrable amount of peni
cilhn and it is not tin
likely tint the two re
lapses of meningitis
which occurred at two
and four weeks after the
accident were associated
with inadequate concen
trations of penicillin
within the meninges
owing to Its continual
escape with CSF from
the nose We have seen
a similar leakage of
J\N 6, 1951
British
MrniCAL JoLPSAi
3
SPHENOIDAL SINUS FRAC^I jRC WITH RHINORRHOEA
penicillin from the subnrachnoid into the subdura'
space m an infant after head injun (Smi h ct al
1946, Case S) J
How common is such profuse rhinorrhoci ? In o
79 cases of cerebrospinal flu d rhinorrhoca lot due to
sphenoidal sinus injurj the rhinorrhi a is profuse n
onlj four cases These patients hu rge tears in n a
tion to the frontal or ethmoidal su s i ic cxpla la-
tion of the high incidence of protu c rl i lorrhoea m
sphenoidal sinus tears must be anat nu. and due to
the fact that the dural tear establish a c nmunication
between the cistema chiasmatica and the iij,e By con
trast the subaraehnoid spaces oser the frontal po' are
small, so that profuse rhinorrhoca from tears f thcr
forward is correspondingly uncommon
The time of onset of the rhinorrhoca after in r> in
these five patients was \ariable It came on at i iicc in
two cases, but was delayed seven to ten davs la two
cases and nine weeks in the remaining case Siiv 'i van
ability IS seen in all groups of traumatic rhim rhoea
The onset of rhinorrhoca depends not only on i ic type
of fracture but also on whether the dural tear is tem-
porarily sealed by blood clot or brain tissue Tor this
reason rhinorrhoca after anterior fossa fracti ls ma\
begin seven to ten davs after injurv when th oedema
of the surrounding brain tissue is subsiding t pulped
brain is Iiqucfrd and the blood clot is undergo g organ
ization Other factors arc neccssarv to cxpla the very
delayed onset which is sometimes met with
Acrocele — With such a ready access tc he basal
cisterns, atr may enter the cranium tnd seen on
X ray examination of the si ull In one c for the
first month after injury air was seen m i le subdural
space, ventricle and cisterna chi isnutica out not in
the brain Tig 2 shows the air m this cisb i, and such
localization should suggest that the dur tear is in
relation to the sphenoidal sinus
Other Signs
Presenauon of Smell — ^Theoretically if the bony
damage is confined to the sphenoidal si us region and
docs not extend into the cthmoids the sense of smell
should be preserved, and this was in fact so in two of
the four patients whom we have had under investiga
tion Nevertheless, no absolute reliance can be placed
on this observation for not only may severe frontal
sinus fractures occur without disturbance of smell, but
in apparently isolated sphenoidal cases the olf iclory
filaments may be damaged cxtracranially pirticularly
when the brunt of the injury is borne faciallv
Injury to Neighbouring Slriieiiins — Clinic il evidence
of damage to the hypothalamus and pituitary gland
(diabetes insipidus inverted sleep rhythm glycosuria
or obesity), to the optic chiasm or to the carotid artery
was present in two of the five cases One patient had
Paranasal Sinus rractlircs In Closed Head Injun (200 Cases)
Incidence of Damage lo Parasella Slruclures
Paranasal
Sinus
Fracture
1 No
1 of
Cases
IIvpo-
IhaJamic
Syndromes
Chhsmal
Injury
Carotid
Aneurysm or
Fistula
Cases
Without fracture of the
sphenoid
With fracture of the
184
7
7
3
14
sphenoid
16
5
'
6
Total
200
12
to :
4 ;
20
• Sis patienls had a -ombmallon of these symptoms
diabetes insipidus the other hid a visual field defect
due to damage to the optic chiasm and also a carotid
aneurysm The accompanying Table, compiled from
our 200 cases of paranasal sinus fracture following
closed head injury shows that, though these neighbour
hood signs are commoner in the presence of a sphenoid
fracture they are by no means rare with fractures
involving the other paranasal sinuses
Risk of Intracranial Infection
Three of our five patients developed meningitis in all
instances pneumococcal, two within a weel of injurv
and the other sight months later Two of these cases
occurred before penicillin was available and vvere fatal
The third patient was treated with penicillin recovered
from the meningitis and subsequently underwent a sue
ccvsftil fascial repair of his dura (Case 2)
In our total senes of 84 cases of cerebrospinal rhinor
rhoea the incidence of intracranial infection was 19%
Thus It would seem that the risk of meningitis is greater
With sphenoidal sinus fr ctures than with fractures of
the other paranasal sinuses
The close proximitv of the basal cisterns’ renders
patients with sphenoidal sinus fracture particularly
liable to meningitis an 1 dural repair should be done
as soon as possible Another reason for early opera
tion IS that if meningitis supervenes and the rhinorrhoca
IS profuse it may be difficult to establish an adequate
concentration of pen cilhn in the C S E bv intrathecal
injections
Diagnosis and Operative Treatment
The dillicultics of obtaining a satisfaetorv repair of a
dural tcir over the sphenoidal sinus may be consider
able but they can be overcome if beforehand the pos
sibilitv that the tear is over the sphenoidal sinus has
been susp"ctcd and the operation has been planned to
provide a cooj exposure of the sella turcica region
Radiographic demonstration of a fracture of the
sphenoidal sinus may be cxtremelv dilTicuIt but this
lesion should be suspected when in the absence of radio
logical evidence of a gross fracture of the posterior wall
of the frontal sinus or of the roof of the ethmoid there
is profuse rhinorrhoca Additional evidence in favour
of the sphenoidal location of the trauma is the pres
cncc of iir m the cistvrna chiismatici, as shown by
radiographs
Faced with the possibihtv that the C S F is escaping
through the sphenoidal sinus region the suigeon must
be prcpaicd to make a full bifiontal exposure and if
need be to divide olfactory tracts vvhieh arc functioning
normally
The intradural approach for dural repair as used bv
Julian Taylor (Eden 1942) is the only vv ly by which
these sphenoidal tears can be fully demonstrated A
bifrontal flap is turned The dura is then opened along
the anterior limb of the flap on each side of the sagittal
sinus, and the inner surface of the dura covering the
frontal and ethmoid sinuses is inspected for tears first
on one side and then on the other If no gross tear
sulficicnt to account for the profuse rhinorrhoca is
found the anterior fossa must be widely exposed The
anterior end of the sagittal sinus the falx, and one or
both olfactory tracts must be divided It is then possible
lo retract both frontal lobes freely and thus to obtain a
good view of the optic groove and sella turcica (Fig 3)
I
Fio 3 — Case 2 Operation sketch Uifrontal flap diMsion of fnU and mi ittal sums frontal fot Hole in
anterior wall of sella visible after rcmosal of arachnoid of cistcmn chiasniatica (ft) 11 , fn,,,, (-.) PMch of
fascia lata applied I tispcu ssnn iiinn
For full inspection of the anterior wall of the sella it is
necessary to open widely the arachnoid of the cisterna
chiasmatica
The dural tear may be quite small and easily missed,
and the proximity of the optic nerves and chi ism, and
of the carotid artery, adds^to the difficulty of the explora-
tion and of the repair In two of the three cases in this
series that were repaired the tear was found in the
anterior wall of the pituitary fossa beneath one of the
optic nerves , in the third case it lay over the tuber-
culum aoUae In each case the hole in the dura w is
repaired with a stamp of fascia lata which lay snug and
was a owed to adhere by natural processes We prefer
t'^mporal fascia because it is uniform in
thickness more pliable and more likely to remain and
adhere where it has been placed
Tins method effectively stopped the rhinorrhoea m
our three cases Four years after the operation all were
well and working , there had been no recurrence of
rhinorrhoea and no post operative meningitis
I he mam fc itui oper^, on arc illustrated b\
liic following case
* n -
>n' 0 Ucd in a car icciJcnl in
German! on Ma> b mslaincd severe facia
'"'"rfrlm ‘•r ".r I’ftns of both cje. i centra
block frictiirc of iht r p fnctnrc of the nose and
of the rieht malar anl v, bones and fnelure of
he 6th thoracic verb,, bid paraljvis of the
left sixth and seventh I ]]c bled from both
nostnls and for^^ameK ' j.echarge
of blood stained C S F , . , , j gmssl)
impaired at each nostril '
The facial fractures v,^ , d after a proph) lactic
in rathecl injection of ’Op, p^„„,,,b„ Ue>s
later the patient devclc.^ j. bilateral rhinorrhoea
and pneumococcal memni ,,„en,ic
fissure m the sella turcica ^^dl^Era^hs'nkcn dunng
Jan 6, 1951
SPHENOIDAL SINUS FRACTURE WITH RHINORRHOEA
fiRmsn
Medical Journal
5
(he first month after injury showed intracranial air at van
ous times m the subdural space ventricle and the cislerna
chrasmatica {Fig 2) The significance of this latter finding
has already been mentioned
Operation to repair the dural tear and stop the rhinor
ihoea could not be undertaken for some weeks The patient
was down to Oxford from Germany two weeks after the
accident and at that time he had a relapse of hts menin
gitis and was developing collapse of his right lung with
bronchopneumonia which persisted for some weeks When
ever he was turned on one or other side C S F escaped
from one or both nostrils, and it was easy to collect samples
for penicillin studies at two hourly intervals
By June 22 his general condition was satisfactory for
operation and his CSF normal though the rhinorrhoea
was still present Because radiographs suggested a fracture
into the sphenoidal sinus and had also shown air in the
cistema chiasmatic i a wide exploration was carried out
after a preliminary lumbar intrathecal injection of 10000
units of penicillin A bifrontal bone flap was turned to the
left The anterior fossa was explored intradurally and the
dura covering the frontal sinuses orbital roofs and the
ethmoidal regions looked quite normal The olfactory
bulbs and tracts also looked normal and though at this
' stage of his Illness smell had partly recovered on the right
side it was clearly necessary to sacrifice them divide the
anterior extremity of the sagittal sinus and the falx cerebri
and retract both frontal lobes in order to examine thoroughly
the sellar region (Fig. 3) At first nothing abnormal could
be seen but when the arachnoid of the cislerna chiasmatica
was separated from the anterior wall of the sella an area
of bare wWte bone (0 4 cm in diame(cr) was disclosed on
the tight side below the optic groove and above the
diaphragma sellae In tlie right edge of this bare area
under the medial edge of the right optic nerve was a hole
through which passed a sleeve of arachnoid containing
abundant C.S F When the arachnoid was cleared a probe
could be passed through this hole into the sphenoidal sinus
The bony hole was plugged with fibrin foam and then
covered with a stamp of fascia lata A second patch of
fibrin foam was placed on the anterior wall of the s^a
between the right optic nerve and internal carotid artery
(Fig 3) The falx was then stitched bad into place and
the dura bone and scalp were repaired in the usual way
Subsequent progress was uneventful The rhinorrhoea
ceased immediately and did not recur The maxillary frac
ture which had been treated by internal splinting healed
in good position The left facial palsy recovered sponlane
ously and completely but there remained constderable
deafness of the left car and a scarred but intact ear
drum The spinal fracture which was treated by a spinal
jacket consolidated with a wedge deformity His left
external rectus made no recovery and subsequent opera
tions on his extraocular muscles in order to banish the
diplopia were only partly successful
When seen four years after the accident the patient was
well and fully employed in administrative work
In this case the dural tear wax limited to the anterior
wall of the sella, and so tar as we were able to ascer
tain so was the fracture The rhinorrhoea did not
come on until six days after the accident and was accom
panied by pneumococcal meningitis which relapsed on
two occasions in spile of energetic treatment with peni
cillin and sulphonamides Much CSF escaped from
the nostrils, and with it pemcillm The patient s general
condition did not permit of operation until six weeks
after the accident because of his jaw fractures memn
gitis and bronchopneumonia Anything short of an
extensive bilateral intradural exploration of the anterior
fossa would have failed to reveal the dural tear and
this operation entailed sacrifice of his already partly
damaged sense of smell The indications for such an
extensive operation were the profuse character of the
rhinorrhoea m the absence of radiographic signs of gross
fracture of the frontal or ethmoidal sinuses and the
presence of air m the cisterna chiasmatica The final
result may be regarded as highly satisfactory in view
of the extensive and severe nature of hts injuries
Tears in the dura may be multiple hence the surgeon
must always satisfy himself that the tear which he finds
IS the one which is responsible for the rhinorrhoea and
that a dural defect further back vs not being overlooked
Such a possibility at operation can be envisaged by
studying, the following case record \
Case 3
In 1938 a jouth aged 18 was involved in a motorcycle
accident and sustained a compound depressed right fronlo
parietal fracture comminuting both walls of the frontal
sinus and the anterior elhmoids on the right side Special
orbital views were not taken and from the routine views
there was no suspicion that the sphenoidal sinus was
involved
The fracture was elevated at another hospital on the day
of the accident Cerebrospinal fluid rhinorrhoea tva*
observed from the riglil nostril on the day after the acci-
dent and It continued for five weeks and then stopped But
a month later profuse rhinorrhoea began from the left nostnl
and continued for six months The patient Was admitted to
the Radcliffc Infirmary and exploration was advised but the
day before operation the patient developed pneumococcal
meningitis from which he died 10 days later
At necropsy in addition lo the signs of meningitis two
distinct fractures were demonstrated One linear fracture
ran down the back of the right frontal sinus where part of
the bone was missing and the dura was adherent to the
mucosa but there was no actual tear of the dura A second
fracture ran across the left optic groove and here the dura
was lorn and a hole 0 4 cm in diameter led into the
sphenoidal sinus
Wc may assume that the rhinorrhoea from the right
nostril followed the fracture bchind^the right frontal
sinus and healing finally occurred by ihc dura and stmts
mucosa becoming adherent The left rhinorrhoea was
due lo the sphenoidal sinus fracture Owing to seplal
variations and injury rhinorrhoea from one side ma>
on occasion result from a contralateral dural tear
It would have been casj to miss this sphenoidal
tear with operatise exploration limited to the side of
the known fracture We do not adsocale bilateral
exploration in all cases of traiimalic rhinorrhoea There
arc some cases of frontal and ethmoidal fiacture in
which the clinical and radiographic signs proside clear-
cut evidence of a unilateral lesion But whencser there
IS suspicion that the leakage is through the sphenoidal
sinus the exploration should be bilateral
Summary
In a senes of 84 cases of C S F rhinorrhocs following
closed head injury n dunl tear over ihc sphenoidal sinus
was found m 11 (13%) and was the only tear in relation
to the paranasal sinuses in 5 (6%)
The mam clinical characteristic of these five cases was
the protuseness of the rhinorrhoea due to the fact that
the tear Involved the overlying cistern chiasmatica Another
sign which may be helpful m diagnosis is the radiographic
demonstration of air m the cisterna chi ismaiica as m one
of these cases
Neighbourhood signs such as CMdence of damage lo the
hypothalamic region optic chiasm or carotid artery were
present m nearly half the sphenoid cases but by themselves
they do not necessaVil> indicate a fracture involving the
sphenoid sinus The preservation or loss of sense of smell
is likewise no clinical guide
6 Jan 6, 1951
SPHENOIDAL SINUS FRACTURE WITH RHINORRHOEA
Djuniii
MrOtCAL JOUHKAL
Operative repair is urgently indic ited The risk of spread
of infection intracrannlly into the basal cisterns is nppreci
ably higher than with fncturcs involving the other paranasal
sinuses
Operative repair is difTiciilt and requires a bifrontal flap,
usually with division of the fal\ and sacrifice of one or
both olfactory tracts Three patients lindens ent successful
dural repair and have since been followed for nearly four
years There has been no further rhinorrhoea or intracranial
infection and all are well and working
Rrrransci s
Caims H (1949) lirttish Medical Journal 1 969
Calvert C A (1942) Proc h Soc Med 35 805
Eden K (1942) Dm J Sura 29 299
Johnson R T and Dull P (1947) Ibid War Surp Suppl 1
141
Smith, H V Duthie E S and Cairns 11 (1946) Lancet I
185
ABSENCE or THE VASA AS A CAUSE
or AZOOSPERMIA
IIV
KENNETH WALKER, ERCS
emeritus Surscou lioyal Northern Hospital Consulttnf;
Urologist Darlforct Hospitals
AND
REYNOLD nOYD, ERCS Ed
Dtnetor Stcnlili Clinus St Johns Hospital Chelmsfortl
and It anstead Hospital
The treatment of azoospermia due to a blockage in
the system of efferent ducts by which the spermatozoa
reach the posterior urethra is admittedly very unsatis
factory Tlic commonest situation for such a blockage
IS the epididymal canal, and when we consider the small
calibre of this canal, Us length ind the prevalence of
epididymitis the frcouency with which it becomes
occluded can easily be understood The next com
monest site for an obstruction is in the ejaculatory ducts,
and this is generally the result of recurrent attacks of
prostatitis and vesiculitis Although the vas deferens
may also be involved in the infection which brings
about an epididymitis, a post inflammatory stricture of
it IS uncommon Genital tuberculosis is an exception
to this generalization In this disease the lumen of the
vas is often obliterated, but as the epididymis is still
more seriously affected this is of no practical import-
ance When the vas is obstructed it is usually from
trauma, and the commonest cause is damage inflicted
on it during the course of an operation such as
herniotomy
To diagnose the exact site of the blockage is not
always an easy task Should there be a clear history
of bilateral epididymitis and additional evidence m the
shape of areas of induration at the lower poles of both
epididymides then it may be assumed with confidence
that the blockage is in these organs But if there is
no such history and if no areas of induration are found
on palpatmg the epididymides, then it is quite possible
that the ejaculatory canals are at fault
How IS this supposition to be confirmed or refuted 7
textbooks suggest that catheterization of the ejaculatory
ducts should be carried out for this purpose But
unfortunately this advice is much easier to give than to
follow Tlie openings of the duets on the slopes of
the vcnimontanum m ly be so placed tint even when
clciriy seen it is mechanic illy impossible to pass a
filiform bougie along them One of us (K. W ) remem
bers Witnessing an expert it catheterization at work
and was not impressed with the results of his si ill A
probe was forced into the lumen of the ducts through
a direct vision posterior urethroscope employing air
distension, but such a-manauvre as this was far more
likely to produce n stricture than dilatation Trauma
of the ducts must be rigorously ivoidcd
Anotlier method of diagnosing in obstruction in an
ejaculatory duct is to expose the vas at the neck of the
scrotum and to inject into it i solution of indigo
carmine, noting afterwards whether this has passed into
the posterior urethra or not Some urologists have
recommended injection of the vasa also ns a thcr ipcutic
measure Hicy believe that the tjactil itory ducts can
be opened up thereby, just is the Fallopian tubes are
opened up by msiifllation We have never seen a block
age removed in this way and dislike puncturing vasa
purely for diagnostic re isons not only because of the
damage inflicted on a delicate structure but also because
of the risk of provoling a descending cpididvmitis
If a case of azoospermia is due to blockage of the
epididymal canils the only possible remedy is to carry
out a vaso cpididyniosiomy Although the results of
this operation arc verv discouraging we cannot afford
to discard a method which m 10'^ of cases leads to the
birth of a child ind m 25% to the reappearance of
spermatozoa in the semen If the patient is prepared
to accept the gamble and a biopsy has revealed active
spermatogenesis in tlic testes this opcrition is justifiable
It can do no harm even if it docs no good Some
patients on whom we hive operated had previously
heard that an alternative method of trcitmcntwas avail
"able Tins was to puncture the testes withdraw
spcrmatozoi from them ind inseminate with the
aspirated fluid Such treatment is, for reasons into
which we do not propose to go utterly useless It need
not even be considered
Vnso-cpididv iiiosloniv
It IS useful, but not essential to give a months pre
hminary treatment with gonadotropic hormone m order
to stimulate spermatogenesis and to ensure that the
epididymal tubes are filled with secretion at the time of
operating After the testicles have been delivered from
the scrotum and carefully inspected the vas deferens
IS separated from surrounding structures at the level
of the head of the epididymis but great care should be
exercised not to imperil Us blood supply The vas is
next incised and some 5 to 6 in (12 5 to 15 cm) of
nylon thread passed down it to demonstrate its patency
TTiis thread is left in sttii to act ns a guide and attention
IS then directed to the epididymis An oval area of the
tunica covering the underlying distended tubules is
removed, and when the tubules are incised a drop of
whitish fluid exudes This is smeared on to a sterilized
covcrslip and the presence of spermatozoa confirmed
The finest round bodied straight needle carrying
40 gauge steel wire, is passed through the wall of the
vas at the lower end of the incision into it and then
through the exposed epididymal tubules Having taken
a good bite of these the needle passes through the vas
again, but at the upper end of the incision It finally
emerges through the skin of the scrotum near the root
Jan 6, 1951
ABSENCE OF THE VASA AND AZOOSPERMIA
Britub
Medicjo. Journal
7
of the penis (see illustration) When pulled upon, this
wire m\aginates the tubules into the lumen of the vas
During the subsequent healing it also acts as an excellent
sphnt to the juncture beuteen the vas and the epididymal
canal The lips of the vasal incision are finally united
to the epididymis on each side by two lateral sutures
of 0 005 m tantalum wire The operation is completed
by returning the testicles mto the scrotum and closing
the latter, without drainage The steel splinting wire is
pulled out on the ninth day
The real object of this paper is not so much to descnbe
the details of the operation of vaso epididymostomy as
to call attention to anomalies of the vas which may be
accidentally discovered in the course of performing iL
In about 10% of the patients operated on by us either
no vas at all was found or else the vas was reduced to a
thread like structure devoid of any lumen Theoreti-
cally, absence of the vasa might be due to one of two
causes — congemtal absence or disappearance as the
result of some previous disease Reference to embryo
logical and anatomical literature suggests that the
former cause is an uncommon one
That the second cause — disappearance through
disease — is tbe more likely explanation is supported by
what we found in three or four cases At the,level of
the neck of the scrotum a vas was discovered, but on
tracing it downwards it gradually narrowed, and 2 in
(5 cm ) before it should have joined the epididyims it
disappeared altogether It was noted that where it
existed the vas was tortuous, sohd, and very friable On
cutting mto it a creamy fluid exuded, as though the
vas was in a state of coagulative necrosis Sometimes
an opaque hne marked the previous position of the vas
m that part of its course from which it was absent
There was nothing m the patients’ chmcal history to
throw hght on the nature of the disease which had .
attacked the vasa and had led to their disappearance
In two patients a somewhat similar condition was
found m the epididymal canal When seen through the
tumca covering them the epididymal tubules had a light
yellowish colour, and when cut into they were found
to be solid On pressure a fluid exuded sometimes con-
taining a few spermatozoa and sometimes without them
Agam it looked as though some form of coagulation
or fatty necrosis was in progress In yet another two
cases the vas ended abruptly 2 in above the epididymis
m a kmd of corkscrew, recalling the termmal portion of
the normal vas Here, congemtal malformation may
well have been the explanation
Conclusion
What IS the moral to be drawn from these observe
tions 7 The first and most obvious is that in all cases
of obstructive azoospermia, and particularly if an opera
tion IS about to be undertaken to remedy it, the vasa
must be very carefully palpated through the scrotum
Every effort must be exerted to make sure that they
actually join the epididymides Through neglect of
this precaution one of our patients had been submitted
to two years of useless hormone treatment by a specialist
before he came to us for operation It is true that
m some cases it is difficult to trace the whole course
of the vasa until they meet the epididymides, but if
the preliminary examination had been more careful
some of these exploratory operations might have been
avoided The second lesson to be learnt is that sterihty
IS occasionally the result of some pathological condition
of the vas the nature of which is still obscure It is
to be hojied that further research will throw light on
this interestmg problem
The commercial production of adrenocorticotropic
hormone in Britain has been in the stage of planning and
organization for some time under the aegis of the Nation il
Research Development Corporation the Government agency
set up three years ago to undertake commercial exploitation
of Government owned patents and other technical projects
The three Government departments involved are the hlinistry
of Health Medical Research Council and Ministry of Food
which has organized the collection of some thousands of
sheep cow, and pig pituitary glands weekly from slaughter
bouses up and down the country solved the problem of their
preservation and delivered them to the five pharmaceutical
firms who are co operating in the attempt to produce
ACTH to the required standards of punty and activity
One of these firms Organon Ltd has just delivered its first
batch of product to the Ministry of Health which is rigidly
_ controlling distribution since supply is far short of demand
and likely to continue so unless the efficiency of the manufac
turing process can be greatly raised or a synthetic substitute
discovered An annual production of 800 g seems the
probable maximum There is no likelihood of cortisone
being made in Britain since its manufacture in about thirty
complicated low yield stages from ox bile is covered by
American patents and in any case there is probably not
enough British ox bile available to start with It will be
recalled that the Ministry of Health recently began monthly
distribution to 50 hospitals (24 teaching hospitals and 26
other hospitals nominated by regional boards) of 6 g corti
sone and 3 g ACTH imported from the U S A at about
$50 a gramme
8 Jan 1951 CONTRIBUTIONS Of MODERN GENETICS TO MEDICINE
B*min
MrniCJU. Journal
SOME CONTRIBUTIONS OF MODERN
GENETICS TO MEDICINE
DY
NORMAN f 3 BAILEY, MA
Slaltsitaan Department of Medicine Unit i ruty oj
Cambridge
, Modern genetics stems from the work, published m
1866 of the Augustinnn monk Gregor Mendel, who
occupied his leisure b\ growing edible pens in the
momstcrj girden Mendels work went nlmost tin
noticed b> his contempornnes, nnd it was noT until
1900, ifter the ground Ind been prepircd bj the great
adsmccs in cytology during the eighties and nineties
thnt Its importance wns rccogni7Cd more or less simtil
taneously bv de Vries, Correns, and Tschermnt Tor
just half n century now genetics Ins m idc rapid ind
constant progress and has found application to the who e
range of lising organisms from viruses ind bacteria to
man himself It is with the latter that medical genetics
has hitherto been mainly concerned though the former
will probably occupy an increasingly important place
m the subject
It IS the purpose of this article both to indieate
the scope and importance of medical genetics and to
emphasize the unique opportunities which exist for
doctors to collect and use gcnctical data The main
fields of application will bo covered with particulhr
reference to the practical use to be made of gcnctical
theory Special attention will be given to methods of
recording dat i so as to ensure tint the m iximuni
amount of information can be extracted from them
and some of the special uses of family pedigrees will
also be mentioned
There is no need to do more than make a passing
reference to the elementary principles on which practi
cally the whole of genetics is based Both of Mendels
laws may be summarized under the single heading of
particulate inheritance according to which the basic
units of heredity arc material particles — the genes —
which arc transmitted unchanged from gcncrition to
generation The first law, the law of segregation states
that characters arc controlled by pairs of genes which
segregate or separate from one another during the
formation of germ cells and pass into dilTcrcnt gametes,
which contain only half the full (diploid) quota of
chromosomes and are therefore termed haploid The
pairs are restored at fertilization Thus the genes arc
shuffled by segregation and redealt to the next gcncri
tion Ch iracters controlled by genes may also segre
gate, and different types will appear amongst the
offspring in certain definite proportions The second
law, the law of independent assortment stales that when
two or more pairs of genes segregate simultaneously they
do so independently of each other This law has had
to be modified by the existence of linkage Briefly
chromosomes and therefore genes m different chromo
somes are shuffled independently but genes in the
same chromosome, m which they arc arranged in a
linear order tend to be handed on together segregating
and recombining however to an extent which depends
on their distance apart
* random element introduced by the
/ shuffling process the analysis of genetical data must
incvitibly appeal to the ideas of uncertainty ind prob
ability associitcd, for cximplc, with polcr or bridge
With experiment il plant or animal breeding the element
of uncert iinly can often be considerably reduced by
using large progenies In man on the other hind not
only arc families small but it is often difficult to find
m images between individuals of the ippropriatc genetic
constitution However, special methods ire availab'c
for dealing with these diffieultics, and a surprisingly large
amount of useful Information can often be extracted
from ipparcntly unpromising d ita
There IS another fundamental genetic phenomenon
which must be mentioned , that is, the occurrence of
mutations Mutation is perhaps most salisf ictorily
defined as the beginning of a heritable vnnition II
can be applied to cither genes or chromosomes A
gene mav suddenly though with extreme rarity, undergo
a spont incoiis change to a different form, and this
chingc may be reffected in the characters which the
gene controls Again chromosomes mav be present
in abnorm il numbers or a piece of one may breal off
and cither be lost (deletion), or become reattached the
wrong way round (inversion) or even joined on to a
ddferent chromosome ftranslocaiion) Tlic word muta
tion should be applied only to the act of change in i
hercditiry unit New genes which suddenly appear
through mutation arc called ‘ mutant genes and
the ch iracters to which they give rise ‘mutant
characters
Much of the early work on genetics was carried out
by I H Morgin and his school who bred the fruit
fly Drasopiuhi mcUmoqnUcr litvrally bv the million
Tliouqh these studies mav seem somewhat remote from
medicine, the hereditary meeh ini'ms thus elucidated
have in fact proved to be of univcrsil application
Contributions to I’laiit nnd Animal Brccdin}.
Substantial eontribulions have been made by gcncties
towards increasing the production of food particularlv
in the cercil group Considerable increases in the vield
of miizc Were obtained by using brcedinc techniques
designed to produce new varieties of hvbrid corn
Again the manufacture of textiles h is been aided bv
producing cotton plants with longer and stronger fibres
and by breeding sheep with heivicr and finer fleeces
Useful work his also been done on the resistance of
plants and mimils to pests nnd disease Turthcr
examples of adv inees in both plant and animal breeding
could be given almost indcfinitclv
Medic il Applications
It IS well known that the rare phenomenon of muta
tion can be considcrnblv speeded up by x ray irradiation
Various striins of the mould Pciucillinni were irradiated
and a search w is mule for high yield mutants The
process was then repeated, with the result that m less
than a year a fivefold to sevenfold increase in the yield
of penicillin was obtained under standard growth
conditions
Genetics has also something to say aboiil another
aspect of antibiotic therapy The genetic study of bac
tern indicates that strains resistant to penicillin strepto
mycin and sulphonamide drugs may originate through
mutation The antibiotic eliminates the susceptible
bicteria and gives the resistant mut ints a chincc lo
survive and multiply A thorough understanding of
Jan 6 1951
CONTRIBUTIONS OF MODERN GENETICS TO MEDICINE
BRtma
Medical Jouwul
9
this mechanism will make it increasingly easier to plan
the clinical use of antibiotics in such a way as to mini
mize the risk of the development of resistant strains
Although one of the essential ingredients of the evolu
tionary process is the variability provided by mutation
most mutations are deleterious for organisms which
are fairly well adapted to a steady environment Under
ordinary conditions it can be shown that most fully
recessive mutant genes that are capable of detection will
he latent for thousands of years before becoming mam
fest However, heavy irradiation of the germ plasm can
occur through faulty technique in radiology and is an
even greater danger with the use of atomic energy in
peace and war This may result in a very great increase
in the natural mutation rate producing an appreciable
deterioration in human heredity It is a sobering thought
to consider that an atomic bomb falling m a highly
populated region will probably cause more deaths in
succeeding generations by genetic damage than it will
at the time of the explosion by blast heat (lash and
irradiation
A word should be said about the possibility of using
experimental animals for the study of comparatively rare
inherited defects For example canine haemophilia s
I a sex linked recessive condition as is human haemo
philia and it is also very similar clinically^ Again
haemolytic disease of the newborn due to incompati
bility between the bloods of mother and offspring also
occurs in certain animals notably mules horses dogs
and rabbits But so far the analogy with man is not
complete injury m animals occurring only after birth
through the absorption of maternal antibody from the
colostrum When genetic and clinical conditions are
sufficiently close in both man and a suitable experi
mental animal it is to be hoped that the far greater
numbers of the latter available may simplify research
and lead to substantial advances
Much of the fascinating work in medical genetics
has been done on rare abnormalities such as haemo
philia or Huntington s chorea The number of different
conditions that have been studied is very large indeed,
and It is most unlilely that the average student or
clinician will ever personally encounter more than a
small proportion of them However, several characters,
particularly serological ones are by no means
uncommon
There are now eight main blood group systems
ABO MNS, P Rhesus, Lutheran Lewis Kell and
Duffy, which are apparently inherited independently of
each other Thus with these and the attribute of sex
and the ability or inability to taste phenylthiocarbamidc
(PTC) we may have as many as 10 of the haploid
number of 24 chromosomes of man distinctly marked
In searching for linkage these are the characters most
worthy of examination It is difficult to over emphasize
the importance of genetics in serology and the extreme
relevance of this field to everyday problems confronting
practitioner and specialist alike Common applications
are to problems of relationship and disputed paternity
Medico legal Work
One of the best I novvn elementary cases is that of
Mrs W, who found on returning home from hospital
that her baby had on its back a piece of adhesive tape
bearing the name B The baby at the B house
was labelled W Had the babies been interchanged
or had someone been careless with the labels ? The
bloods of the six persons involved were as follows
Group
Mr B AB
Mrs B O
Baby W O
Genoiype Group Genolype
GAGE Mr SV O gg
gg Mrs W O gg
gg I Baby B A GAGa
I or GAg
In this table G denotes a dominani gene and g a recessive one
\yhcn the pair arc identical they are said to be homozygous when
different (as GAg) they are called heterozygous A recessive gene
IS one which cannot make us influence felt in ihe individual v. hen
present with a dominant but which after segregation (separation
from Us dominant partner) may have the chance to manifest itself
in Ihe offspring
There had clearly been an accidental interchange of
babies before the mothers went home This is doubly
proved, for Mr B could not have had an O child nor
could Mr and Mrs W, both of group O, have produced
an A baby In this extreme case no recourse to any
other group is necessary The same kind of princip'e
applies to disputed paternity Although a decisive result
IS by no means always the case, the use of as many
blood groups as possible makes such a result very much
more likely In this country extensive use of the avail
able knowledge about the inheritance of blood groups
has not yet been made although considerable steps
have been taken towards this in the United States Only
recently a court refused to accept quite definite evidence
which clearly dispro ed paternity It seems likelj that
about SO’Jo of the men against whom affiliation orders
have been made have been wrongfully accused It can
be shown that by recourse 16 the full series of eight
blood groups now available abbut 62% of those wrongly
accused could be exonerated As about 7 200 affiliation
orders are made eve'ry year and 2 000 men go to prison
for non payment, it seems that preventable injustice is
occurring on an appreciable scale
It is usual for most textbooks to saj that paternity
tests can only be negative — that they can only on occa-
sion disprove paternity, and can never provide positive
-evidence in its favour This was the case when know-
ledge of blood groups was in its infancy but is no longer
true with the existence of rare antigens or combinations
of antigens For example suppose a woman of rhesus
constitution ede/ede has a baby with the extremely rare
genotype C''de/cde while the putative father is also
C"de/cde The conclusion would be irresistible — though
perhaps not in a court of law In a similar manner a
number of rare abnormalities might occasionally give
positive evidence of paternity In 1921 there was
reported in Norway a paternity case in which a normal
mother had given birth to i brachyphalangic child
Brachyphalang) is inherited as a rare simple dominant
and the court accepted the fact that the putative father>
was brachyphalangic as evidence of hts paternity
Now evidence concerning blood groups may be
required by either party in divorce or kindred proceed
mgs and a doctor called as an expert witness may find
himself exposed to the following criticism He may be
asked Is it not true that genetic factors are subject to
sudden and unpredictable changes, called mutations, and
IS not evidence depending upon their inheritance there
fore suspect f Can it be asserted that the genetic factor
in question has not in fact changed in this way '> It
IS essential to be prepared for such opposition and it is
worth while giving a correct reply here in some detail
U would run something like this
The hereditary mechanism of all higher organisms is of
the particulate or Mendehan type which depends for ils
10 Jan 6, 1951
CONTRIBUTIONS OF MODERN GENETICS TO MEDICINE
Drrii H
MitrtCAL Jni F^AL
opcniion upon the extreme pernnnence of the hereditary
factors themselves Were these to chans,c or mutate in as
many as one individual in even a few thousand the system
would break down A study of such miUitions throughout
the widest selection of living organisms demonstrates that
a mutation rite of as high as 1 in ^0 000 individuals is
extremely rare and this frequency is hardly ever exceeded
Inhentance in man is of the same type and these conclii
sions are strictly applicable to him However it is un
necessary to depend on mere analogy for a knowledge df
human mutation rate It has been possible to study this
in several instances in which it proved to be when most
frequent of the same order of rarity ns in other animals
The error introduced into blood grouping by mutation Is
very unlikely to be greater thin I in 50 000 and is probably
less
Few legal cases can have been decided in the present
century in which the possibility of mistake was not
considerably greater than this
The Rhesus Group nnil Haemolytic Disease
The importance of ivoiding serological mcompati
bility in blood transfusion is well known With the
ABO group one merely has to ensure that the transfused
erythrocytes arc not agglutinated by the recipient s anti
bodies With the rhesus group, on the other hand, the
danger is that a rhesus negative woman may become
immunized by transfusion or pregnancy, with the con
sequent risk of haemolytic disease of the newborn in
her offspring The practical implication that every
female rcquinng transfusion, or who has or who may
become pregnant, should be rhesus tested does not of
Itself involve genetics But in the case of a rhesus
negative woman for whom one wishes to assess possible
risks the mvocatiop of gcnctical principles is essential
It should be noted that the great majority of cases of
rhesus incompatibility arc in connexion with the antigen
D although the others (C,C c d o, etc ) may very occa
sionally stimulate the production of antibody
When a rhesus negative woman marries a rhesus
negative man there is no danger, as all the children will
be rhesus negative (Yhc mating is of type dd x dd )
Even if she marries a rhesus povitive man (dd x Dd or
dd X DD) the risks are still small m spite of the con-
trary assertions of newspaper articles Provided tlic
woman has never been transfused or mjcctcd with even
minute amounts of rhesus positive blood the chance of
the first child suffering from haemolytic disease is almost
zero and the chance for the second child still extremely
small The combined chance of disease in the first four
or five children is uncertain, but is perhaps no greater
than 5% if the husbands genotype is unknown With
homozygous (DD) husbands this chance would be about
9%, and with heterozygous husbands (Dd) it would
be only 1 %
If, however, the woman has already given birth to
an affected infant, further rhesus positive children arc
very likely to be diseased and only rhesus negative
children wiU be healthy If the father is heterozygous
then there is an even chance of a healthy child at each
subsequent pregnancy On the other hand, if the father
is homozygous, all future children are likely to be
affected , but, even so, there is still some chance that
a child diseased at birth will respond to treatment and
eventually be healthy
Collcctuig Data and Preparing Pedigrees
It IS a peculiar characteristic of genetic data that they
are often collected only incidentally during the course
of work primarily concerned with some other depart-
ment of medicine More pedigrees of rare inherited
abnormalities have been pi iced on record by physicians
in the course of their ordin iry worl than have been
amassed by research workers making special efforts to
obtain such material A lot of information of a genetic il
nature normally arises m clinic il, pathological, and
socio medical investigations
Carefully and properly col'ecled fenctic dila have a
certain permanence iboiit them which is not so charac
tcnstic of other branches of medicine where new
methods of observation and experiment frequently make
older work obsolete Although the svstematic and
detailed construction of pedigrees is of fairly recent
ongin, It IS likely that they will be of immense value
for centuncs to come
Dcsidcral t for Good 1 nmily Record
Let us consider some of the special points to be
observed in Iccping a good family record Clinical
histones of individuals arc usually perfectly adequate
for tlicir immediate purpose But when their informa
tion on hereditary f ictors is later extracted and collated
It IS only too common to find that vital links in the
chain of inference arc missing because their relevance
was not apparent at the beginning
While there is nlrcidy m existence a vast but relatively
untapped mine of information in the records of general
practitioners which could be made to yield valuable
results if systematically investigated, it is also certain
that a great deal of promising data would in fact be
found to be of little use because of the f iilurc to
observe one or two clcmcnlan precautions in the
original compilation
Obviously m reporting an abnormality or disease
of any kind it is essential to have a full clinical dcscrip
lion, including such items ns the age and sex of the
patient, age at onset of the disease variations in seventy
and frequency of attack, and so on Some indication of
the patient s social background should also be given , his
social and economic status, the type of work he does
etc If IS also important to have this sort of informa
lion about near relatives, especially parents brothers
and sisters (sibs), and children It is these near relatives
that arc the most important — data should always be
obtained about more distant rUativcs if available but
this IS not quite so essential
The usefulness of a family history is naturally depen
dent on the firm establishment of the clinical diagnosis
and in the case of the patient through whom the pedigree
first comes to be noticed (called the ‘ propositus ) this
will normally have been obtained at first hand It
often happens that the doctor will be able to see the
close relatives himself and record his own direct impres
sions — this IS much the most satisfactory state of affairs
But sometimes it is possible to secure quite good second
hand information from the patient himself or other
relatives — for example about members of the family
whom the doctor is unable to sec himself In an exfen
sive study it might be useful to classify the individuals
in some such grouping as “certainly affected ’ “almost
certainly affected possibly affected ’ almost ccr
tainly unaffected, “ certainly unaffected, unknown
etc But in any event there should always be notes on
each individual giving the exact evidence itself Should
it prove impossible to obtain information about nnv
particular relative of the generations and degrees of
Jan 6, 1951
CONTRIBUTIONS OF MODERN GENETICS TO MEDICINE
British
Medical Journal
II
Unship studied, the reason for the failure should always
be stated
When collecting together data on several related per-
sons in this manner one should" clearly indicate who
is the propositus — the individual who first brmgs the
family to notice, or primary case in the genehc sense
Failure to do this may seriously affect the mterpreta
tion of genetical data, particularly in the sib method of
analysis, which is discussed below
Another vital piece of information which must not
escape the record is the existence of a consangumeous
marriage Positive or negative information on this
point IS equally valuable In many cases it is not
sufficient merely to state that husband and wife are
related, that they are cousins for example one wants
to know m greater detail, for instance whether the
mother of the husband and the father of the wife are
brother and sister Cases of twins should also be care
fully noted, together with any positive or negative infor-
mation on -whether they are identical or not
- It is useful to be able to lay out an interestmg pedigree
"so that the salient chara-teristics may be seen at a glance
There are various ways of doing this, and some of the
mam symbols in common use are shown in the accom-
panying Table In complicated pedigrees especially
Pedigree Symbols in Common Use
0 0 42 $^ Oie<i before a
~ f ' spectfed
O Femile O O A ^ AfitcteJ
0 Hale © CQ
Sex unknown
^ Number of I dividuals
^ ihewn collect! e!y
^ Proposl us
1 II III Oen rat ons
1 2 3 Indi fduali n 4 given generation
Condition unkonwn
o 0
Stilfb rth
Carrier*
6 i b
experience of only a certain proportion of all the avail
able cases If one collects consecutive cases of a
condition, then the correct proportion of affected indi
viduals among sibs (which is the most mformative figure)
is obtained by calculating the proportion among the
remainder of each sibship ignoring the propositus If
two members of a single sibship present themselves
mdependently then that sibship must be counted twice
over For example, if a sibship consists of four normal
and three affected mdividuals, of whom two of the
affected persons appear for examination independently
while the third is found only as a result of a family
mquiry, then that sibship is counted twice, each time
as four normal and two affected
Two points stand out First, that the right method
of analysing the data must be employed Second, that
useful mformation can be obtained from a study of
sibs only It follows therefore that there is no need
to be discouraged because of the dffficulty of seeing or
gammg information about distant relatives It is worth
making a special effort to obtain detailed information/'
about parents, sibs, and children, but less than this can
be of use The same thing is true of data which are
collected m the hopes of finding a genetic linkage There
IS not space to go mto these methods now suffice it
to say that the general principle is to test
the propositus together with his sibs and
parents if available for the possession of
suitable characters other than the one
used for selection — say, the individuals
blood groups or their ability to taste
PTC, etc
Sibs bore to
parena
Huthifld tnd wHe
6 ^ d
cT^
cA)
TVfO qsttTs^o
(Vanml twins
fetl of a ptiJgrit of pofydactyf/
those involving the inheritance of two or more
characters, special symbols may have to be employed
For further suggestions, reference may be made to
Ruggles Gates s Human Genetics vol 1, p 4
/
Ascertainment
The modern methods employed for interpretmg gene
tical data normally involve some kmd of statistical
analysis The reliability of these analyses depends on
a knowledge of the way in which the material was col-
lected — what IS usually called the method of ascertain
raent Uncertainty about ascertainment will affect the
validity of the results Somehmes it is possible to make
some allowance for ignorance of the method of ascer-
tainment, but naturally there is an inevitable loss of
certainty
One might in theory collect all the cases of a parti
cular condition m a given neighbourhood or distnct
Such a procedure would readily lend itself to simple
interpretation but would in general be exceedmgly
troublesome to carry out It is usually possible to gain
Eugemc Prognosis
A fev’)' comments on the practical value
of a knowledge of linkage may be men
cm rmra tioned here Unfortunately such know-
ledge IS stdl somewhat rudimentary in
man, but with the mcreasmg number of
marked chromosomes especially those
due to the discovery of new blood groups,
' quite extensive data on human linkage
are potentially within our grasp
Many serious human defects are
heterozygous conditions, and some of
them do not become apparent until
after the normal age of marriage, as m Huntmgton s
chorea Children whose father or mother has developed
that disease may wish to marry Though they are
apparently healthy it is probably undesirable for them
to do so if between the ages of and 40 they are
destined to develop' a progressive mental deterioration
leadmg to insamty which they will moreover transmit
to half their offspring At present such indivi-
duals can only be told that the chances are exactly'
equal they may be afflicted in this way, or they
and their descendants may remain perfectly noimal
If, however we knew of a number of genes controlling
ordinary characters, such as eye colour blood group's
PTC tashng, attached ear lobes etc , which were linked
with Huntmgton s chorea, then the situation would be
much clearer We could say perhaps whether the chances
of developing the disease or not were very remote or
very considerable, and this might have far-reaching
effects on the decisions of the patients concerned Simi
larly in famihes with sex linked it would be
invaluable to know whether a
recessive gene or not
12 Jan 6, 1951 CONTRIBUTIONS OF MODLRN GHNLTICS TO MEDICINE
It IS commonly stid tint in hmilics inrboiiring n
serious rcccssiAC defect no one should mnrr> i ne-iv
rchtne, tint nnrrnges bttuctn cousins should be pro
hibited While the ethics of this sort of problem ire b}
no meins cis), in isscssment of the probibihtics m
\ol\ed nn> well proside useful puidmcc If there is
any doubt ibout how to do this the idnec of a com
potent geneticist should be sought
Suppose, for cMniplc, i niin Ins Ind i brother who
died of juscnilc inntirotic idiocy, which is due to in
lutosonnl recessoe gene (one not on iso\ chromosome)
and tint he wishes to nnrry Ins fiisi cousin If there
are no other ciscs of the dtseise in the fimiH then the
clnncc ihit both the min and his cousin ire hetero
zsgous is 1 m 6 The clnncc of i single child from
shell a marrnge being in idiot is therefore 1 in 24 The
couple mi\ be prepared to iccept this risl but it is
desirable that lliej should know wh it it is TTic ch mces
of basing in itTected child arc grcitcr if thes base more
than one and the probabilitj of producing a hetero
zjgous child which though itself unallcctcd is cipable
of transmitting the gene, is considcrabls higher In
any case a consanguineous marriage ilssays mcrcises
the likelihood of bringing to light an undesirable
rcccssisc gene
To take another case, consider a woman who Ins a
brother who dies of true haemophilia, which is a sex
linked reeessne What arc the prospects both for her
and for another brother who is unaflcclcd The
unaffected brother cannot carry the gene at all md his
descendants will all be free of it The ssoman, on the
other hand has a 50% clnncc of carrsing a gene for
haemophilia If this is so she will tnnsnm the diseisc
to half her sons and half her daughters will be earners
It IS interesting to nolo tint the linkage of the loci
(gene positions) for haemophilia and colour blindness
has already been used for eugenic prognosis in f iniihes
exhibiting both these defects In a certain Dutch famiK
It was possible to say that the colour blind daughter hid
a 90 „ chance ol carr\mg a haemophilia gene vslicrc
her normal sisters h id onh a 10% chance Proba
biUtics like lUchC arc clearly of much greater saluc Ihm
the more usual 50% chances as in the previous c\ implc
No doiibi when the human germ plasm is ns well charted
as that of Drosophila melanognsicr this kind of irgu
ment will be used as a matter of course in the proven
tion of congenital abnormalities
Aids to Diagnosis and Preventive Medicine
The discovery of a hereditary factor in the aetiology
of a disease by no means implies that further medic il
progress is impossible Heredity and environment inter
act and determine jointly the condition of a person
Thus an ailment which depends to some extent on
heredity may be ameliorated cured or even entirely
avoided by suitable treatment or alteration m living
conditions
There are occasions when a knowledge of hereditary
background can be used as an aid to diagnosis Tor
instance a mao was admitted to hospital having lost
considerable blood by haematemesis The diagnosis lav
between gastric ulcer cirrhosis of the liver with ocso
phageal varices and Banti s disease One physician
however happened to know that the man s father had
suffered from a mild telangiectasis and had had the
typical spider s webbing of the nasal mucous membrane
Now multiple telangiectasis, or Osier s disease is due to
fiitmai
Mm cAi. JotfUKAt
a dominiint gene ind it vv is suggested that perhaps
the piticnl in question also hid the disease — with a
tclani leetatic spot m the gastric mueosa The surgeon
explored, found i I irgc lei ing lett itie focus and excised
It Svmptevms disappeared md there was no recurrent
Incmorrhijs If i dominint gent always li is full
expression then it is true tint no treitmenl vsill prevent
the be tiers from exhibiting the abnurnnhtv nexerthe
less some form of tre ilmcnt nnv be available is in
the suriieil (re iimcnt of polydietvly
* In either cireiimst incts jenetic Inowlcdgc may help
to deteet hereditary diseases m their prcchnical stages
when full advmtigc cm be lalcn of preventive
me isurcs to forest ill the ippc irancc of niamfcsl disc ise
Ihuv fimiliil achohirie jitinUice is a dominant, condi
lion for vvhieh spKiieelomv is a common propHylaei c
measure Moreover it ein ilways be recognized pre
clinie ilh by certain I iboralory tests Although it would
not be feasible to ex mime whole popuhiions of mdi
vidiials sp-cial cx imin ilion can b,. made of the relatives
of known siiffercrv When lihoratory tests show an
■ ndivuhial to be cirrving the gene the spleen can be
removid if indicitcd and clinical discisc probably
aveftev!
Conclusion
It cm be Slid with full jtislificalion that a deeper
undersi indini of the j incite il basis of a disease will
often help to fill m the gaps m a purely clinical approach
and miy male mitcrial contributions to both trcitnicnt
and prevention The field of ipplieition of genciies
to medicine is a wide one There is the study of muti
tion which has been ipplicd to the ndvnncemcnl nf
antibiolie iher ipy and wliieh has also emphasized some
of the dangers ittiched to x ny irradiition and the
use of itomic energy There is the studv of the
inherit nice of blood groups .and other common
characters as in aid to idenufyme individuals parti
ciil irly m p itcrnitv caves The rhesus blood groups
are of sp cial interest ind pcnetical thcorv is parti
culariv vahiible in estimating the risks run by rhesus
ncguive mothers The possibditv of gaming neyv
insiclit into various diseases in man bv an invislication
of closely similar diseases in experiment il inimiK is
also worthy of consideration Genetics cm be used as
an aid to diienosis and for sugccsting eertam pro
ccdurcs m prcvcnlise ^medicine Another important
application is to eugenic prognosis when one wishes
to assess some of the dangers att.achcd to parenthood
where there is the possibditv of heritable disease
There cm be no doubt that medical genetics has
a very real contribution to make to the cause of sulTcr
ing humanity and that its power and seopc yyill crcith
increase and spread in the ye irs ahead
In his annual report for 1949 Dr Hiieli Paul medical
officer of health for Smelhwici. writes It is unfortunate
that many of these [invesliealtonal] facilities arc only as id
able lo die priclitioncr llirougli i senior menher of the
hospii it staff fon example the fcncral practitioner may
find grcnl difficully in getting tlie rcsull of an cxanlinalion
of the piticnls blood i baclcriologicai cvimination or a
radiograph except by making an ippomlmcnt with the
appropriate consultant in the hospital This max be excellent
hospital etiquette but it is dc( lorabtc medical practice and
the technic i! facilities of die hospital particularly those
issocialed with bicteriology and biochemistry should be
imnaediaacly available lo the general pracUlioner without the
intervention of i third person except when the general
practitioner asks for an opinion as welt as for a lest
Jan 6, 1951
PROPERTIES OF ISOPROPYL CHLORIDE
British
Medical Journal
13
AN INVESTIGATION
OF THE PROPERTIES OF ISOPROPYL
CHLORIDE
BY
JOHN E ELAM, BA,, MRCS, LRCP
Anaesiheiist Barnet General Hospital
AND
M. L NEWHOUSE, MB, M.RCP
Assistant Physician Barnet General Hospital
MacDonald (1950) has described the anaesthetic pro
perties of isopropyl chloride ( proponesm ’ ) This
agent has now been used by one of us (J E) in
approximately 50 cases and has been found to have all
the properties that anaesthetists have long been waiting
for The induction was pleasant for both anaesthetist
'and patient, and with only a gas-oxygen-isopropyl
chloride sequence the most resistant patient could be
smoothly led to the deepest plane of anaesthesia with-
out cough or struggle This anaesthetic seemed td be
equally successful for both major and minor surgery
good muscular relaxation was provided and recovery
was both rapid and pleasant It was noticed that cardiac
irregularities occurred but as these are not uncommon
with sodium thiopentone trilene, and cyclopropane,
they were disregarded In order to avoid these irregu
larities several patients were induced with gas, oxygen,
and ether and then a change was made to isopropyl
chloride, but cardiac irregularities were still noticed in
each case though the patient suffered no ill effects
Unfortunately a case of complete circulatory failure
occurred
The patient a man aged 48 was a case of moderately
severe thyrotoxicosis Before operation he had had five
weeks rest in bed and three weeks premedication with
Lugols iodine Electrocardiograms taken three weeks
before operation showed sinus tachycardia but no evi
dence of myocardial damage Under treatment he had
gamed 5 lb (2 3 kg) m weight and his pulse rate fell
from a range of 120-110 to 90-80 For the induction
of anaesthesia the nitrous oxide-oxygen-isopropyl chloride
sequence was used The induclion was very smooth and
quiet The patients colour was good throughout and
at no time was there any indication that some difficulty
might arise An endotracheal tube was passed very easily
and the patient taken into the theatre Just 10 minutes after
the induction was started as the patient was being lifted on
to the table he gave a slight cough and his colour changed
to ashen grey he was found to have complete cardiac
arrest Controlled respiration with oxygen was continued
Ihroughouf the attempts to restore him Cardiac massage
with intracardiac injections of adrenaline and procaine were
given and after 45 minutes the heart was restarted but he
died a few hours later (Roualle 1950)
After this experience it was decided that electro
cardiographic records should be obtained during the
admirustration of that anaesthetic For this, two healthy
young men were chosen Only nitrous oxide, oxygen,
and isopropyl chloride were used
Case 1 — The patient was a man aged 31, and the opera
lion was for the lemoval of a semilunar cartilage The
preliminary record was normal (Fig 1) thereafter records
were taken at approximately five minute intervals, and more
often when the pulse was irregular (Fig 2) After five
minutes Lead II showed a regular rhythm but with suppres
Sion of P waves and depression of the S-T interval at 11
minutes a curious rhythm had developed with dissociation
of the auricular and ventricular elements The P waves
were absent for several beats and then appeared with no
constant relation to the QRS complex there was a high
degree of A-V block and possible nodal rhythm At 17
minutes the rate was 200 a minute and there were multi
focal ventricular extrasystoles , at 19 minutes the rate was
100 and irregular with absent P waves suggesting auricular
fibrillation A Trontinuous record was then taken which ^
showed variations between multiple ventricular extrisystoles
to a coarse auricular fibrillation Five minutes later he
reverted to a normal rhythm which continued to the end
of the operation
Case 2 — ^This patient was a man aged 25 and the opera
tion was for the repair of the flexor tendons of the right
hand A normal record (Fig 3) was
obtained before the administration of
the anaesthetic Under the anaes
thetic he showed less severe changes
than the first patient but (Fig 4) at
five minutes the rate was 120 a
minute with multiple extrasystoles
and depression of S-T intervals m
some complexes Extrasystoles were
still appearing in the record taken at
seven minutes At 10 minutes the
pulse rate had dropped to 60 and was
sti/1 slightly irregular but there were
normal contractions At 25 minutes
and at the end of the operation after
45 minutes anaesthesia the rhythm
was normal
Fio 3 — Case 2
Pre anaesthetic
record normal
tracing ^
Fig 1 — Case 1
prc-anaesihctic
record normal
tracing
5 Mms
Lcdil H M Min^
Udd H
-
17 Dm,
Le,.d E 19 Mins
Uadi 20 Mins
•'l,'
Lead I
w-
€1
j j* i
Lead M 30 Mins Ua dE
' r i .Li
I. 7 ^ ,
Flo 2 — Case 1 Consecutive rccoids while under anaesthesia (a) Depression of S-T inteml and
absent P waves (5) Dissociauon of P waves and QRS complexes Possible nodal rhythm (c) Mulu
focal ventricular extnsysiolcs rale 200 (d) Auncular fibrillation rale 100 fe)
with two heals showing increasing P-R jntervaL (/) Coarse auncular to
normal rhyihm
16 Jan 6, 1951
PYRUVIC ACID LLVCL IN DIABLIIC ACIDOSIS
,, Cwuii
MtmcXL JCKASAL
INDIVIDUAL OBSERVATIONS
no 2 — mi m pynuic ncid locls irt
four patients ind fall in blood su(,ar and
nse m alkali rcserac in two patients in
which ihtse were followed X X
= control patients O O = cocarb
oxylasc treated patients
cocnrbox>l tscand
riboflaain in the
t r c 1 1 ni c n t of
dinbctic acitlosis
h istens the rite
of clinical re
coverv and the
return to normtl
Il\l 1 of the blood
p\ru\ic acid and
ilL ill reserve We
found the r lie of
improvement to
be similar to that
seen in pnred
controls b"cn
identic il treat
menl with fluids
ind insulin with
out the addition
of coc irbo\)lasc
ind riboflavin
neither in the 12
alloxan - diabetic
ribbits nor in the
4 acidotic diabetic
pitients was there
in> difference in
the rate of clmi
cal recovery the
f ill in blood
P)ruvic acid ind
blood sutar or
the rise in ilLah
reserve
T he test of
such a treatment
in human patients
IS of course, more
diflicult since
comparisons arc valid only when comparable eases arc
contrasted , this was more easily achieved with the
rabbits than with the patients Thus while we have
confirmed the evidence of defective pjruvic acid o\i
dation in diabetic acidosis we found no evidence that
this was due to a deficiency of cocarbo\)lasc Normal
pyruvic acid metabolism requires not only cocarboxy
lase and other co enzymes but also the intcgrit> of the
enzyme protein it may be that in diabetic acidosis the
protein component of the enzyme system is inhibited or
partially inactivated as it is in sodium arsemte poison-
ing (Peters, Sinclair, and Thompson 1946)
Summary
The blood pyruvic acid level was found raised during
diabetic acidosis in 12 alloxan diabetic jabbits and 4 acidotic
diabetic patients
Supplementing a standard treatment for diabetic acidosis
by cocarboxyla^ (vitamin B, diphosphaie) and riboflavin
did not appear to accelerate further the recovery from
diabetic acidosis as measured by the rate of the fall of the
raised blood pyruvic acid level the fall of the blood sugar
the rise of the alkali reserve or the observed clinical improve
ment
We wash to express our thanks to Dr Russell Fraser for his
help and advice to Dr F Wngley for suggestions and to
Miss Shirley Looker for her assistance with the biochemical csti
mations We are also indebted to the Diabetic Association for
the grant of a Lund Research Fellowship to one of us The
cocarboxylaso used in the investigation was kindly supplied by
Roche Products Ltd
Rertarsers
Banpa^^I, Ochoa, S, and I’clcrs R A (1939) Dhehem J 33
Boiilin R Uhry P Meyer F W„ and Bonfils S (1949) Pr
ni^d 57 6^9
Biicdin),, I Worlis 11 I I cm H D and Lsturonne D (1942)
Amrr J mrd id 204 S38
Dultv L (1945) J lalh Had 57 199
I ncdcniann T I and Haugen G L (1943) J blol Chem
147 41 V
Gooilliatl, R and Sinclair If M (I9-.0) Ibid 132 II
Guest G M (1942) Amirr J Dli Child 64 401
king, L J (1917) MtcroandyjU in Medical Ihucheintttry
Oiiirchill I ondon
Matkees, S (19)9) 7 Urn Mrd 145 354
am) Meyer J VV (1945) I xprnertna 4 31 19V
(1949) Srh»rL mrd Wirht 79, 931
Martin H I and Weriman M (1947) J elm Inirjt 26 217
Peters R A Sinclair II M and Tliompson R II S (l9-,6)
Utorhem J 40 VI6
Van Slyke D D and Cullen G E (1917) J blol Chem 30
289
ORAL rLNICrLLIN IN CHILDREN
iia
S A DOMADIS, MD
Senior / tcliinr in Child Ilrilth Unierniy oj Sheffield
JOHN L. IMIR\, MD, DCH
Clinnal I'lilhtdoiisl Lecltirrr m ffiillwlogy Unnersid
of Sheffield
AVD
SMI IIA M SlLSSARl, I) Sc
III clrriido^ist Penionrtriilnr in hi.cirriolop'i Uinersit\
of Sheffield
(I roni the Childrens Hospital Sheffield)
It has been shown Ih it sitisf ictory bacteriostatic blood
levels nrc altnincd in infants by the oral administra
tion of penicillin (Henderson and McAdam 1946
Buchanan, 1946 Ilusson 1947 Moseley I94S) The
oril use of penicillin in infants has therefore been
widely adopted In older children and adults (he condi
lions for absorption of penicillin from the gastro
intestinal tract art not equally favourable probably
because of the higher gastric nciditv
Charney ct <il (1945) suggested the use of an antacid,
and It was shown (Gydrgy ct etl 1945, Burke cl al
1945 Cohlan c( o/ I94S Hildick Smith ef o/ 1950)
that the combination of penicillin with an antacid is
cITcctivc in maintaining a bacteriostatic blood level
Hoffman cl al (I94S) were unable to confirm this They
obtained satisfactory results by giving penicillin three-
hourly m a dose of 1,400 units per lb (450 g) of body
weight All authors agree that penicillin should be given
on an empty stomach to ensure maximal absorption
Owing to the conflicting reports on the oral dose
required and on the value of antacids it was felt that a
study of these points was necessary before penicillin
could be used by mouth for therapeutic purposes
Methods
Seventy SIX children aged 2-15 years were given peni-
cillin two or more hours after a light breakfast It
was in tablet form each containing 200,000 units Tlie
dose given varied from 1,000 to 7,000 units per Ib of
body weight Sodium citrate, 3 g m 1 oz (30 ml ) of
flavoured water was used as antacid It was given
immediately before or after the penicillin
Jan 6, 1951
ORAL PENICILLIN IN CHILDREN
BMTCH
Mxsioll Journal
17
'The blood and penicillin serum levels were estimated
by the capillary tube method described by Fleming
(1943), using whole blood inoculated with Richard s
stram of Streptococcus pyogenes The serum used for
assay was from capillary blood collected m Wrights
capsules Blood was taken before the penicillm was
feiven and three hours later In many children blood
_was also taken at other intervals A total of 208 test
doses Were given, involving 632 pemciUm assays
Results
The Table shows the number of children grouped
accordmg to the pemciUin dosage and the use of
antacid, with the numbers in each group havmg a serum
penicillin for only a few hours every day mav hate
therapeutic effects the aim of most penicillin regimens
in chmcal practice is still the attainment and mam
tenance of a bacteriostatic blood level for the whole
period of treatment ' On this basis the results of the
present work are discussed
Hoffman et al (1948) claimed satisfactory results with
unbuffered penicillin with single doses as low as 1 400
umts per lb of body weight, and they recommend this
dose at three hourly intervals but a study of their data
reveals that of 137 children aged 1 to 12 years 41 had
a blood level of less than 0 03 unit per ml three hours
after the oral dose With a shghtly higher dosage this
level was found in 11 out of 85 children
Number of Children with Serum Penicillin Le\el of 0 06 unitlml or More at Various Times after Ingestion of the Drug
Ho«n After loge^tton of Penicillm
\b of
Wiihom Antacid
With Antacid
Weight
0
I
2
3
4
0
2
3
4
1 000-1 999
i.000-2,999
0 of 20
7 of 7
11 of 12
10 of 12
9 of 20
0 of 12
0 of 12
0 of 18
0 of 20
9 of9
g of16
16 of 20
0 of9
3 000-3 999
0 of 20
3 of 3
5 of
.S
3 of 5
13 of 20
Oof ^5
0 of 2
0 of 20
5 of 5
19 of20
I of5
4 000-4 999
Oof 20
6 of
6
5 of 6
16 of 20
Oof 6
0 of 4
0 of 20
6 ofd
19 oftO
I of6
5 000-5 999
Oof 20
6 of
6
13 of 13
16 Of 20
5 of 13
2 of 6
0 of 20
1 of 1
19 of 20
1 ofl
6000-6 999
Oof 30
7 of
7
7 of 7
29 of 30
7 of 7
2 of 7
pemciUin level of 0 06 unit per ml or over at various
tunes after the mgestion of the drug
The level of 0 06 unit per ml of serum was considered
the immmum necessary for satisfactory therapy in con-
ditions usually treated with penicillm In this, as m
previous works, the serum level three hours after the
mgestion of the drug was arbitrarily chosen for the
evaluation of this method of pemciUin administration
It can be seen that in the groups of children receivmg
less than 4,000 units per lb of body weight without
antacid only 22 of 40 (55%) had an adequate bacteno
static level at three hours Of the 40 children receiving
4,000 to 5,999 units per lb of body weight without
antacid, 32 (80%) had a bacteriostatic level three hours
after the administration of the drug Finally, in the
group without antacid, 29 of the 30 children (97%) who
received 6 000 to 6 999 uniU per lb of body weight had
a level of 0 06 unit per ml or over at three hours
When antacid was given together with the penicillm,
9 of 18 children (50%) receiving 1 000 to 1,999 umts
per lb of body weight 35 of 40 children (87%) receiv-
mg 2 000 to 3,999 units per Ib of body weight and
38 of 40 (95%) receivmg 4 000 to 5,999 per lb of body
weight had a bacteriostatic level three hours after takmg
the penicilhn tablets
Fifty seven children received the same dose of peni
cilhn on two occasions the first time without antacid
and the second time some days later with antacid ill
the other conditions of the test being exactly the same
In 42 children the bactenostatic level at three hours was
the same on both occasions — namely either above or
below 006 umt per ml (in 3 below m 39 above) Four-
teen children had a level less than 0 06 unit per ml
at three hours without antacid and a level of 006 umt
per ml or more when antacid was given One child
had a level of 0 06 without antacid and a lower level
with antacid
Discussion
Although it has been suggested (Jompsett et al 1949)
that the mamtenance of bacteriostatic blood levels of
Similar results with unbuffered preparations and doses
of approximately 1 SOO to 3,000 units were obtained by
Reisman et al (1947), Cohlan et al (1948), and Hildick-
Smith er al (1950)
In this mvestigation an attempt has been made to
estimate the amount which had to be given m order to
obtain a serum level of at least 0 06 unit per ml three
hours after penicillin was taken The results show
that even when the dose given by other investigators was
doubled (4 000 to 5 999 units per lb of body weight)
8 of 40 children (20%) had at the end of three hours
a serum level of less than 0 06 umt per ml
It was only when 6 000 to 6 999 units per lb of bodv
weight were given orally that the desired effect was
achieved in all but one of 30 children (97%) It would
seem that doses smaller than 6 000 umts per lb without
antacid cannot be relied upon to maintain a bacteno
static serum level of at least 0 06 unit pi-r ml over a
period of three hours
According to Reisman et al (1947) and Cohlan et at
(1948) the 'addition of antacids did not improve the
results when 50 000 to 100 000 umts were given to
children aged 2-12 Hildick-Smith e/ a/ (1950), admmis
tenng a dose of approximately 3 000 umts per lb of
body weight with an antacid obtained blood levels of
008 umt per ml or over in all 10 children at the end
of three hours
The experience from the present senes demonstrates
the value of simultaneous administration of an antacid
With a dose of 2 000 to 5,999 units of pemcilhn per lb
of body weight a blood level of 0 06 umt per ml or
over was obtained in only 54 of 80 test doses (67%)
without antacid compared with 73 of 80 test doses
(91%) when antacid was given
The companson in individual cases of the results with
and without antacid, but on the same dose, further
demonstrates this point Of 57 children thus compared
14 had a satisfactory level at three hours only when
an antacid was given, but m one the effect was the
opposite
lb Jan 6, 1951
ORAL PLNICILLIN IN CHILDREN
Midjcal JOVUNAL
It IS difTicuIt to cstimite the magnitude of the economy
in penicillin achieved by the addition of an intacid
The results show that, when no antacid is given, at Icist
6.000 units of penicillin per lb of body weight must be
administered to ensure a level of 0 06 unit per ml or
over at three hours in more than 90% of the children
When an antacid is given the minimal dose likely to have
a similar effect, ns it appears from the table, is i 000
units per lb of body weight On this basis the addition
of an anticid would permit a reduction of approxi-
mately 50% in the dosage of penicillin
It IS gencnily advised that if penicillin is given orally
the dose should be three to five (Ponchcr and Unna,
1950 , Gyorgy and Lee 1947) or four to eight (Hcrrcll,
1949) times larger than the parenteral dose , As the
recommended single dose for parenteral use in mild
and moderate infections is 500 units per Ib of body
weight (or 4 000 units per lb per 24 hours in eight doses)
even an eightfold increase in dose is inadequate for
oral use When no antacid is given nothing short of
12 times the parenteral dose can be trusted to produce
satisfactory blood levels in most children This would
mean that a 10 year-old child would need more than
1.000000 units of penicillin a day, oimoicthan 1,500000
units if m antacid vverc given at the same time Another
disadvantage is the three hourly administration Tins
method of giving penicillin must therefore be weighed
against the parenteral injection of a slowly absorbed
preparation such as procaine penicillin in 2% aluminium
monostcarate which is cfTcctivc if given once every
24 or 48 hours (Emery ct a! 1949)
Summary
Blood levels of penicillin after oral administntion of the
drug with and without an antacid have been estimated in 76
children who vverc given 208 test doses
To attain a reliable bacteriostatic level of 0 06 unit per
ml three hours after the ingestion the single dose of pcnicil
hn should be not smaller than 6 000 units per lb of body
weight — that is 48 000 units per lb of body weight in 24
hours
Simultaneous administration of an antacid may allow \
reduction of this dose by approMinatcty 50%
We would like to thanl Mrs E L Henderson matron of Ash
House Hospital School and licr nursing stall for tbcir co opera
tion and assistance The penicillin tablets were Itndlj supplied
by Glaxo Laboratonvs Ltd Greenford Middlesex
RcrcRENcns
Buchanan J L (1946) Lancet 2 '60
Burle F G Ross S and Strauss C (1945) / Ainer med
/Iss 128, 83
Chamey J Album H E and Bcrnlnrt F W (1945) Science
101 251
Cohlan S Q Lewis J M and Scligman E (1948) Amcr J
Dis Child 75 15
Emery J L Rose L M Stewart S M and Wayne E J
(1949) British Medical Jotirncil 1 1110
Fleming A (1943) Laiieet 2 434
Gyorgy P and Lee H F (1947) Adiances in Pediatrics 2
151 Interscience Pub) New York
Vandergrift H N Elias W Coho L G Barry F M
and Pilcher J P (1945) J Amcr rued /Ijs 127 639
Henderson J L and McAdam I W J (1946) Lancet 1 922
Herrell W E (1949) In Brennemann s Practice o) Pediatries
rr „ v^bapter 44 Prior Hagerstown
^ ~ F McNair and Wtntlock C M
Pedialr 32 1 ^ ^ ^
Husson G S (1947) Ibid 31 651
CIiiM/i 23 93
™ P I" Mitchell-Nelson s
lextbooK of Pediatrics 5th ed Saunders Philadelohia
V Reisman H A^^^Goldfarb A A and Molloy^M (1947)'^ imer
^°'"tia 4 qv^ A Goldstein O and McDermott W
U949) J Ainer med Ass 139 555
INSTILLATION OF STREPTOMYCIN
INTO THE PERICARDIAL SAC IN
rURERCULOUS PERICARDITIS
ID
R 1> K COE, MD, MR CP
< piisiiliinf, l'li}sician II rvf MIddItsex Hospital lair
Medical tlifisirar St Heller Hospital Carshallon
Several eases of tuberculous pericarditis treated with
sirtptomvcin by the intramuscular route have been
ri-porttd m the literature Reference is made in a report
of the Mcilical Research Council (1950) to one ease of
tuberculous pericirdiil cllusion in which streptomycin
w IS injected into the pericardial sac, but no details or
dosige were given T ipic ii al (1950) also report the
ease of I man of 4f with chrome pulmonary tuberculosis
who developed a pcrieardial cITusion Tlicy gave five
injections of streptomycin totalling 1 15 g, into the
pericardial sac vvilhoiit obvious improvement
fhe following case is recorded because it shows that
strcplomycuv injected into the pericardial sac, in con
junction with streptomycin hy the intramuscular route
constitutes a sife ind rational form of treatment in
tuberculous pericirditis with effusion, and that it mav
be bcncficiil, csficcnllv in eases characlerircd by rapid
re iccumiihtion of fluid iftcr paracentesis
C we Report
A Post OlTicc clcclncian aged 20 whose brother was sulfer
ing from a pleural effusion vv is found to have enlarged
Ildar glands on mass radiognphy in September 1948 He
w-is asked to ittcnd for further radiological examination
but did not do so On J iniiarx 8 19*9 he developed sub
sternal pun mal ii'c fever ind vomiting and two vveekv
later was admitted to hospital
Examination on admission on Januiry 22 revealed a well
built pale ill min moderately dyspnocic and with a tern
pcraliirc of 103 2 F (39 s C) There wax pulsus piridoxus
and moderate engorgement of the neck veins the apex beat
was jivst palpable in the fvCtlv left space m the mid-clavicuht
line and cardiac dullness extended from 1 in (2 5 cm ) out
side the riclil sternal border to the mid axillary line Pen
cardial friction was beard over a wide area of the prac
cordium I here was m area of dullness with bronchial
breathing and increased vocal resonance over the left lower
chest posteriorly near the midlinc The blood pressure was
130/70
Diagnostic pericardial paracentesis on J iniiarv 26 yielded
dark straw coloured fluid which grew Ulscohariiritim
iitlierciilosis on guinea pig inoculalion but direct examination
and 1 ovvenslein ciilliire were negative
On January 30 be developed cardiac tamponade and
32 or (907 ml) of fluid was aspirated with immediate relief
of symptoms Signs of tamponade returned however in
24 hours and a further 22 07 (624 ml) was aspirated the
following day Wilhin the next two months recurrent
tlmponade necessitated five further aspirations and amounts
varying from 14 lo 32 oz (397 to 907 ml) were amoved
on each occasion
Intramuscular streptomycin 0 5 g twice davK was started
on February 12 and alilioiigli this resulted in some lowering
of the temperature the pericardial effusion continued to
accumulate at about the same rate as before It was there
fore decided to give streptomycin into the pericardial sac
On March 24 1 g dissolved in 2 ml of water was injected
into the effusion The procedure was repeated weekly for
another five weeks No adverse effects occurred and after
the third injection there was a considerable drop in fever
Jan 6 1951
STREPTOMYCIN IN TUBERCULOUS PERICARDITIS
BjimsH
Medical Journal
19
The fluid re formed very slowly only 6 oz (170 ml) being
aspirated on two occasions after beginning treatment (see
Chart)
On April 21 he de\ eloped a left sided pleural effusion
which was aspirated several times Intramuscular strepto
mycin was stopped on May 2 because ot toxic symptoms
On May 3 there were signs of superior mediastinal obstruc
tion and a large mass of enlarged meJiastinal glands was
seen on radiological examination Two weeks later ascites
oedema of the legs and enlargement of the liver to 3 in
FLUID
(7 6 cm) below the costal margin were present All these
manifestations were unaccompanied by any notable recur
fence of fever or toxaemia and they slowly subsided with
rest in bed over the course of the next six months
When last seen (May 6 1950) the patient was extremely
well and back at full work and was able to walk five to
SIX miles (8 to 9 7 km ) at a bnsl pace without dyspnoea
Radiologically there was moderate enlargement of the
cardiac shadow with slightly diminished cardiac pulsation
and still some enlargement of the hilar glands on the right
side The blood sedimentation rate was 2 mm per hour
(Westergren 200 mm )
I wish to thank Dr J B Harman for permission to publish
ihis case
References
Medical iCesearch Counal (19^0) Lancet 1 841
Tapie J Laporte J Pmel and Monnier (1950) Pr med 58
226
Medical Memoranda
Perforated Peptic Ulcer of Meckel’s
Diverticulum
A case of Meckel s di\erticulum containing gastric
mucous membrane ''nd presenting with perforation
of an associated peptic ulcer is described The salient
features are discussed with special reference to the occur-
rence of peptic ulceration m these cases
Case Report
A girl aged 7 was admitted to the childrens ward of
Grantham General Hospital at I pm on No% ember 14
1948 She had always been healthy until three days before
admission when she began to complain of diffuse vague
abdominal pain It was noted that the stool soon after the
onset of the pam was dark red On the day before admts
Sion two small stools of similar colour were agam passed
and on that night the pain became more se\ere and was
definitely colicl y in nature doubhng the patient up and
preventing sleep A small amount of yellow fluid was
\omited two hours before admission and the pain then
continued as a dull central abdominal ache There were
no urinary symptoms The bowels had been regular before
the onset of the pain
On examination the temperature was 101 F (38 3 C)
pulse 140 and respirations 24 ^ The abdomen showed
generalized rigidity maximum o\er the lower right rectus
and right iliac fossa Tenderness was present over the
central part and right side of the abdomen
but there was no h\peraesthesia Rebound
tenderness was also present There was
dullness to percussion in both flanks and
shifting dullness could be demonstrated on
moMng the patient to one side or the other
Peristaltic sounds were present There was
no tenderness on rectal examination but a
smear of dark red blood stained faeces
(benzidine +++) was seen on the examin
ing finger The Hess capillary fragility test
was negative and bleeding and clotting
limes were normal A tentatne diagnosis
of perforation of Meckel s diverticulum was
made and operation arranged
At operation performed by Mr F }
Jauch the pentoneal cavity was found to
contain a large quantity of dark red blood
Flecks of fibrin were adherent to the lower
ileum and a small Meckel diverticulum
measuring 3 by 1 cm was found arising
from the antimesentenc border of the ileum
about 18 in (46 cm) from the ileo caecal valve The
diverticulum was adherent to the antimesentenc wall of
the intestine for the whole of its length except for the tip
and was covered with flecks of fibrin At its base there was
a small punched out lenticular perforation measuring i in
(06 cm) in diameter The ileum distal to the lesion was
slightly distended and the coat was bluish in colour The
appendix was normal No other lesion was detected in the
abdomen The diverticulum was then excised together with
a diamond shaped cuff of intestinal wall surrounding it
Free dark red blood was present m the intestinal lumen
The gap was sutured transversely the excess blood mopped
away from the peritoneal cavity and the abdominal wall
closed in layers without drainage
The patient made a satisfactory recovery from the opera
tion being allowed up on November 16 A barium meat
examination earned out oi\^ December 1 showed no abnor
mality and no delay in the passage of the meal through the
small intestine \VTien last seen on January 6^ 1949 the
patient was in good health eating well and ready to go
back to school
Pathological Report — Section shows typical gastric mucosa
with numerous well defined oxyntic cells At the base of
the diverticulum encroaching on both ileal and gastnc
mucosa there is a subacute type of peptic ulcer which
has perforated
Comment
This case is typical m many ways It falls into the
usual age group 85% of the cases reviewed by Johnston
and Renner (1934) were under 16 The perforation was
preceded by haemorrhage — this is a common occurrence
70 to 80% ofesuch perforated ulcers having been asso
ciated with haemorrhage The blood passed per rectum
was said to be unmixed with mucus and this was con
firmed by rectal examination Schuliinger and Stout
(1934) stress this point m the differential diagnosis from
intussusception The ulcer found at operation was mar
ginal — this IS the usual site of ulcer associated with
Meckel s diverticulum — and there was an early attempt
at walhng off the process, a point stressed by
and Singer (1932)
20 Jan 6, 1951
MTDICAI MlMOkNNDA
BtrTtni
MrT»irAi /o'
However, in ccriiin ispccls ihc ense dillers lioni the
typical picture Thus, it occurred in i j-irl of the t i e-.
recorded only 10 to 15% ln\e occurred in fennh
There was an mimcdnte preccdini, hislorj of ihdnnun I
pain of tliree days durilion thoUi h this oee •
sionally occur, it is not common The iculc eohul ^ p un
complained of on the night before admission w is proo
ably due to haemorrhige into the bowel ssilh distensior
of the ileum Gn\ stressed th it there is i m dde
change from relative well being to an acute illness m iiu
acute lesion of Mechel s diverticulum In mv ease then
was no sudden change and it is diflieiilt to st ite whe i
the perforation occurred
My thanks arc due 10 Mr r J Jnuch for pcmmsmti to p ibli
this case and for helpful criticism and ndvic In Mr Jolir llui
and to Dr R B T Baldwin for llic patholoj isal report
Donsld M Hancock Mil f h II
Rrn arsci s
Johnston L B and Renner G (1934) Airri Ginfc O' t
59 198
Schullinger R N and Stout A P (1934) Irch Si/r„ Chi n o
28 44Q
Vaughan R T and Singer 11 A (1932) /Inn Ci,r„ 9f, at'l
Reversible Papilloeclema in
Pernicious Anaemia
It IS recognized that anacmi i m i\ be a factor in the
causation of papilloedcm i >ct reports of its occurrence
in Addisonian pernicious anaemia ire extremely rare
Casp RrpoiiT
A ships boatswain aged Ig was adinillcd to hospital on
February 1, 1949 with severe pernicious antcmia of one
months duration In July 1946 he first bccantc ill but
was inadequately treated His vision had been blurred for
three weeks and three days before admission he noticed
swelling of the ankles
On admission he was gravely ill grossly anaemic and
slightly juindiecd There was slicht pitting oedema over
the sacrum Enlargement of the liver spleen or Ivmpli
nodes was not observed The nutritional state was good
and no source of blood loss was discovered The blood
pressure was 120/50 There was no abnormality of the
heart lungs abdominal organs or nervous system The
urine contained an excess of urobilinogen but no bile salts
or pigments and no albumin
A blood count on Febniary 2 was red cells 1 030000
per emm haemoglobin 49 g per 100 ml MCI!
37 7 ry, white cells 3 000 per c mm Films showed macro
cytosis, poikilocytosis polychrom isia reticulocytes 0 2"
and no malaria parasites
Anahaemin produced a dramatic clinical and Incmato
logical response with a reticulocyte crisis of 29 2"', nine
days after the beginning of treatment On March 19 his
blood count was red cells 4 880 000 per c mm haemo
globin 14 g per 100 ml— a gam of 3,850 000 red cells and
91 g of haemoglobin in 45 days On February 27 a
15 seenL^. mtnutes 10 seconds and bleeding time 2 minutes
twelfth nr^' dis5ppearcd by the
mai after the first week and the Hess test for canillarv
hoTpUar He' lTT''h^ throughout hts stay ,n
m England “ repatrnUon
Ophthalmic Report
mmts'‘airu^"”r contracted, ocular move
•r, s” ns ,=
Ihluinl pvpillorthma v iv more marked on itr n^ht thr
It th left venmiv cnioricmcnt and miiliipl t-tirtl
t i mcirihii's were ot'crvrd Ihc at cries i"cm d ta fr
n iriii I In loll fiinili liacm'ir/ln?*v ovefbp,-cJ Ite dti
u II md more p'lipherally miihiple flirrc-shtp'
I I tot li 11 c in ihc nervr 111 re layer were sewlietcd i- th
mv I itid temporil airav A di-cp oval shap'd ha —
1 r wiih (Ictrlv defined cdie was seen one dive dijr""
Ml p ' I'ly from lli' rlihl opiK disk An lavtr i
■n I *1 I d h icmofth igc projcsied anteriorly frm I
1 ni till of the left miciila and ore d ik dJr "
V 'I V 1 cirtular Incmorthiyc wav sc-a in l! e d
iiirin Ihc next month the rapilloevictin rrtiJi. 3 l'j r’-
m' ' Un MulIi I VI ml icniiy vv-m rithl 6 i|' w h
I) 1 re at le lo f ,'6 left f M 2 not inprp ed w ^
In It' tnemntthares were b'mr ahotb'd pa f ‘
mIl mi 111' sucllin, of the neve headv had >' — *
t , '
' In h IS he pvlinit lompi iired of bhiFcJ vi
i^t e c I viminjlion revl thy reveal'd a f "i
1111 I cr > 'aye Ihpilloi.d'm3 had siibviJcd 3'J tf
1 t p Ir
• ri.h 3| viiiat aciiilv was riphl 6<12 ca-'c"-'^
t 1 II fi 6 2 not cotrcvlable by I'Ov" Seat! :
iiir 111 ih r'v oniinalh seen had b-cn alvoibds '
ih'ir p'viii itcs were vhvcovcrcti vuih dill ciiltv If
01 vtt I 1 . I I'f iiu,iihr Inrnorrhapc was Ivcing aS e'
I o' V , il’ - ident and Ihc pillor of ll c duks was r"
r o K II I c 1 ll ' nrhl side than on the left
CoMvtrvr
I ’ t 1 inopeneus of papilloedema as of most pat!''’
loi 1 I pts of O'dc 113 IS obscure Watkins t! c'
(I'hi.icpo ltd three cases of ihrombocvlopenic putp-T
md I ci'e of macmi i clue to bleeding gastric u'et ta
ill oi winch p ipiDocdcm I vsas notcvl In tlisctissm? th
intcb mism tiiw postiil tied a local reaction of the lisst-ss
of the optic nerves to anoxaemia A general oedema c
the brim due lo the stmt niecbanivm is also mcntioh'd
IS I possible fictor Fbev did not enlarge on this,
but presimnblv mcrcised capillary permeability due tP
oxvgcn lack is rvsponsiblc for the abnormal accumu'a
lion of extr icclluhr niiid It is nol clear why this pio
cess should ilfcct one optic nerve more Ihan the oth'
(in their fourth c isc the left showed clev ition of " ip
5 diopires the rmlil only 1)
Simpson (19 IS) reported three cases of emphysema
vsith papilloedema lie allribiilcd the latter to a rise p'
ccrcbrospin ll fluid pressure from cerebral sasodilatalion
due to oxvgcn lack and cirbon dioxide accumulation
in the arterial blood it is possible lint such a mechamsm
max operate in maemn However these theories impl)
a threshold level of inoxacmia and cerebrospinal flu™
pressure beyond which one vxovild expect papilloedema
lo occur Yet C S r pressure m ly be high and min'
cases of severe aincmn miy bt seen wathout piP'"
oedema being observed riirlhcrmore the swelling nia'
be much more prominent on one side Ihan on the other
It would seem therefore that there must be some local
factor the nature of which is not apparent
This paper is subniillcd by permission of Mr A C Tume'
one FRCSLd Chief Medical Ofiiccr Anglo Iranian on
Company
H A Rrm, MB M RCPEd
W Harris, M RCS, DOMS
Anglo Irnninn Oil Compnn>
RnrcRLNcrs
Simnson T (1918) Dnihh ^fc(^lcal JourtwJ 2
Watkins C 11 Wnpener II P and Drown R NV (194!)
J Ophthal 24 1374
Jan 6, 1951
REVIEWS
Bmtoh
MrorcAi Journal
21
Reviews
DEVELOPMENT OF VISUAL RESPONSES
Kwion Us De\e!opmenl in Infant and Child B}
Arnold Gesel! M D F L llg M D and G E
Bullis Assisted by V llg O D and G N Getman
O 0 (Pp 329 72 figures £2 2s ) London Hamisfi
Hamilton 1950
^This book IS unique m the literature and therefore must
excite interest Its genesis lies in the Yale Clinic of
Child Development, which since 1911 has been con
cerned with the development of earlv human behaviour
Sy an elaborate series of carefully controlled observa
tions — much of it m photocine records through one way
vision screens which leave the child and his attendants
(when present) unembarrassed—the behaviour of the
child and his reactions to various visual stimuli have
been recorded and charted from birth at periodic inter
vals until school age The study has even included the
foetal infant — the prematurely born infant — from the
age of 28 weeks after conception The research includes
an astonishing number of observations relating not only
to visual responses but to the whole system of tonic and
kinetic reflexes concerned in postural activities, m which
the eyes are important agents The study is a fascina
ting one for the physiologist the paediatrician, the
psychologist and the ophthalmologist The authors
conclude that even in his ocular equipment the infant
or child IS not a miniature adult but is qualitatively a
different organism constantly changing and they hope
that if the techniques described are further elabor
ated, an appraisal and supervision of the efficiency and
development of the visual (and other) functions should
be possible from the earliest stages of life
The book is interesting to read but to appreciate
it the reader must understand the American language
Moreover, he must understand that much of the exuber
ance — whereby the eye is described as the jewel of
organic evolution and Tarsitts as leaping around with
suprasonic speed — is truly Amencan in its delightful
enthusiasm
Shew art Duke Elder
RHEUMATIC DISEASES
Manual of Rheutnolic Diseases By W p Holbrook
M D and D F Hill M D (Pp 182 illustrated
S4 25 ) Chicago The Yearbook Publishers Inc 1950
This bool is dedicdted to the genera! practitioner and
jusufies the intentions of its authors They do not
attempt to present a documented scientific treatise or to
cover all aspects of the subject but to provide a pracli
cal guide to diagnosis and treatment especiallv in home
practice They give a timely warning against waiting
for miracle drugs and cures while neglecting the simple
methods directed to preventing the development of
crippling and deformitv and raising resistance by atten
tion to the general health Thev describe a basic routine
bne of treatment which will have a psychological effect
improve the general health and serve as a basis for such
other methods as may be desirable The authors hold
that the most valuable physiotherapy is training the
patients own muscles through carefully directed exer-
cises thus maintaining muscle tone and range of joint
movement and helping the circulation They warn
against excessive use of heat treatments for while
comforting at the time they tend to keep the disease
active and do more harm than good in the long run
Transfusion is often helpful, but vaccines and manv
other procedures which have been used in the past are
condemned as mamlv worthless Gold treatment has
been found beneficial m a large proportion of cases but
demands careful supervision signs of toxic effect being
sought and frequent blood exammations made Clear
instructions for its use are given A valuable feature
of the book IS the attention given to prevention of
deformity, especially in_ home treatment Tables of
appropriate exercises are included, and the authors
emphasize the importance of rest and avoidance of
any exercise entailing over use of inflamed or painful
joints They recognize the importance of trauma
postural and occupational strain, and general wear and
tear in the aetiology of osteoarthritis Excellent illus
trations guide the reader m the use and application of
splints supports, crutches and the like
The authors discuss the most recent developments
clearly but briefly Cortisone and A C T H , the adreno
corticotropic hormone, are fully described from their
own practical experience This is a book which the
general practitioner will find most helpful and which
the specialist max read with pleasure and profit
C W Buckley
MEDICINE IN BULK
The Practice of Medicine By I C Meakins CBE,
MD LED DSc Fdlh edmon (Pp 1,558 £4 15s)
London Henry Kimpton 1950 ,
Gravimetncally considered, this is probably the
weightiest textbook of medicine yet published in
one volume, and of its 1 500 pages over 1,000 come
from the pen of Professor Jonathan Meakms himself
It IS a monument to his erudiUon, to the range of his
knowledge and to his industry Yet the reviewer can
not do otherwise than ask himself to whom this huge
xolume IS addressed Is it intended as a companion
to the student s medical studies or is it meant as a work
of reference for the practitioner t It is too long too
detailed and too much concerned with uncommon
diseases for the first , for the opposite reasons it
cannot play the second role Perhaps its handsome
formal and its wealth of illustrations may beguile the
chmeal tyro into expending £4 15s on its purchase,
but It IS certain that no hard driven student id his final
year would make it the handbook for his qualifying
examination For all this its success is prov^ by the
demand for five editions in four years
These observations are engendered by the increasing
bulk of all the current textbooks of medicine which
reaches a critical level with the present work There is
need for an author who will write for students , who
will limit himself to essentials and principles, seeking
what he may omit rather than what he may include
and who will avoid the meretricious lure of encyclo
paedtsm No textbook can take the place of the great
systems of medicine and those who require information
on rare diseases will always need to consult original
papers and monographs ' 4
The individual sections in this book are excellent Per
haps those on the respiratory and cardiovascular systems
by Professor Meakins and that on the nervous systems
bv the late Dr Peterson, deserve particular mention
The introductory chapter entitled An Introduction to
the Practice of Medicine reveals the broad view and
22 Jan 6, 1951
REVIEWS
Bwrm
htCDICAL JovrsxL
mature wisdom which mark the approach throughout
the book It IS perhaps inevitable that the space dexoted
to some diseases should seem excessive and to others
inadequate thus three pages arc occupied by the section
on acute dilTuse lupus erythematosus three quarters of
a page by the description of Bouchet’s disease while
the common ind important complaint glandular fever
IS allotted less than one page Although it approaches
the limits of portabihtj, this book has many excellences
not the least of these arc its numerous illustrations and
Its fine printing _ _ _
R BoDLra Scott
THE ELDERLY PROSTATE
Leitfaden fur ProstatILer B> Professor J Minder
M D (Pp 68 7 diagrams M 4 80 ) Stuttgart Georg
Thicnie 19‘>0
Most British doctors would probabl> agree that the less
a patient knows about his complaint the better It is
just because of our knowledge that we doctors as a
class are sometimes so troublesome to those to whom
xxe appeal for advice on our own poor bodies But
here is a book which deliberately sets out to tell cxcry
man xxhat may happen to his prostate Anything more
likely to make him a prey of the quack it is diBicult to
imagine
Yet for those for whom it is not intended, young
doctors starting m practice the book would be simply
invaluable The author gives a short and clear account
of the anatomy of the prostate, of the mechanism of its
enlargement and of the way in which this may cause
trouble He draws a useful distinction between the
troubles which age invariably brings and actual pro
static disease, and carefully explains the means by which
this can be recognized With clarity and precision he
describes the pathological changes in the bladder which
gradually develop the means by which to some extent
they may be avoided, and the later effects of bad
pressure on the ureters and kidneys
There is an admirable chapter on instrumentation and
especially on the art of passing a catheter Whether a
patient could be expected to take such precautions is
questionable but there is no doubt that a doctor should,
and many a doctor would be grateful for the hints given
here The author gives a full account of medical methods
of maintaining asepsis in the bladder and of combating
sepsis should it arise, with the most modern methods of
drug therapy Operative methods arc naturally only
referred to briefly but every surgeon will agree with the
remark that whatever new methods may be introduced.
The best method is that in which the surgeon is most
skilled and with which he has obtained the best results ”
This little book is written in very simple German and
with a clanty that is rare It is full of really useful
hints and will amply repay perusal
Henry Souttar
CHILDREN IN COURT
ne Child and the Magistrate By J A F Watson
(Pp 367 12s 6d ) London Jonathan Cape 19J0
^though Mr Watson is not a doctor his book can
be safely recommended to any medical man who is
chnically minded This second edition of his well known
book, largely rewritten and brought up to date, must be
studied as a textbook by every magistrate of a juvenile
court but It IS written in such a way that anyone who
has to do with children can thoroughly enjoy it from
beginning to end Those of us who do not exclude
psychological cases from our out patient clinics will
recognize on every page the children with whom we
arc concerned and it is very important for us to he
able to see these same children through the eye the
human and kindly eye, of this magistrate
If the bool gives one qualms at all, it is by making
one realize what a great deal depends, in the manage
ment of the delinquent who has arrived at the stage of
court proceedings on the clinical sense and the human
understanding of the magistrates and there cannot be
many in whom arc combined (as they are in Mr Watson
and his colleague Mr Basil Hennques) a love of children
With a knowledge of the lavy and of court procedure
Sentimentality will not do The complexities of the
Education Act, 1944, the Children Act of 1948 the
Criminal Justice Act of 1948, and the Justices of the
Peace Act of 1949 have to be known to the magistrate
IS anatomy and physiology have to be known to the
doctor Moreover magistrates need to keep in mind
that it IS the public interest which as a court of
justice, must always be their paramount consideration ”
1 think that general practitioners as well as psychiatnsts
should Jnovv what to expect of the juvenile court and
there can be no better way of getting this knowledge
than throuch the enjoyment of this book Incidentally,
there are plenty of amusing tit bits to help the reader
along
There is one thing which will come as new to many
readers There is a gap in management left by the
serious attempt which is being made to eliminate cor ,
poral punishment This gap is to be filled by attendance
centres provision for which is laid down in the Criminal
Justice Act of 194S However only one exists as yet
Mr Watson has great hopes from this new provision
but one feels that their success will depend not only on
the way they arc run but on their being used by the
magistrates for the right kind of case— that is to say,
for the child who is able to make list of a limited
corrective
D W WiNsicorr
ROOKS RECnVED
Rnlra Is not precluded by notice here of books recently ttcehed
Jealousy lu Children Bjl E Zimsn M D (Pp 236 12i 6d )
London Victor Golinnci, I9J0
Ttrst Aid to the Injured Authorized Textbook of the
St John Ambulnnco Auocintion 40th ed (Pp 2S4 3s )
London The St John Ambulonce Assoastion 1930
What IS Hypnosis i" By A Salter (Pp 94 8i 6d) London
Athenaeum Pitas 1930
Text book of 'Orthopaedic Medicine Treatment by Marti
pulation and Deep Massage By J Cynax M D B Ch
Voi 2 (Pp 335 I8s 6d) London Cnsscll 1930
Practical Gynecology By VV J Retch M D T A C S
FJ C S and M J Nechtow M D (Pp 449 SOs ) London
J B Lipplncott 1930
Surgery of the Shoulder By A F DePalma M D (Pp 438
I40s ) London J B Llppmcott 1950
Surgery of Cataract By D B Kirby AM M D LL D
(Pp 695 240s) London J B Llppmcott 1950
t
A Compantott to Manuals oj Vraettcat Anatomy By
C B Jamieson MD 7lh cd (Pp 736 IBs) London
Geoffrey Cumbcrlegc 1950
Practical Periodontia By H M Robb DDS B Sc (Pp 117
21s) London Geoffrey CiimbcrJcfic 1950
Jan 6, 1951
PROGNOSIS OF FOETAL ASPHYXIA
Bwnsn
Medical Joukkal
23
BRITISH MEDICAL JOURNAL
LONDON
SATURDAY JANUARY 6 1951
PROGNOSIS OF FOETAL ASPHYXU
Doub'ts about the ultimate prognosis of severely
asphyxiated infants at birth constantly assail those
who are responsible for their resuscitation Methods
of obtaimng information lack precision The usual
and less satisfactory one has been to correlate the
clmical findings m a group of children which is
usually speciallyi selected with the birth history
Schreiber* - inquired mto the birth history of 900
patients seen by hmi because of defects such as
cerebral palsy and mental deficiency and found a
history of apnoea at birth in 70% Faber’ mvesti-
gated 99 children with mental deficiency spasticity
or convulsions — m all of whom cerebral atrophy was
demonstrated — and discovered there had been pro
longed apnoea or cyanosis at birth in 22 He thought
that mtrous oxide anaesthesia when given to the
mother with less than 15% oxygen earned with it a
particularly grave risk of asphyxia to the foetus
Belnap and his colleagues * examining 419 defective
children aged 8 months to 14 years ascribed 52%
to birth injury and anoxia Rosenfeld and Bradley’
studied 673 children admitted to a psychiatnc hos
pital for behaviour disorders m order to determine
the effect of asphyxia m infancy on subsequent
behatiour There were 28 children with a history
of difficult resuscitation at birth and 126 who had
had severe whoopmg cough The authors found that
the children with a history of asphyxia showed a
charactenstic syndrome of unpredictable vanability
in mood hypermobihty impulsiveness lack of atten
tion %ar}'ing inability to recall matenal previously
learned and conspicuous difficulty with anthmetic
A syndrome consisting of at least five of these six
traits occurred more than eight times as frequentiv
as in the control group
Preston* reviewed the prenatal and natal history
of a group of children some of whom vvere chosen
for studv because of difficulty at birth This group
* 3 Amer mrj Att I93S 111 1263
Prdijl 19W 16 297
•ibid I9<0 J7 326
•Ar,rr 3 Db Child 1947 4 I
* r dlltrlcs 1948 I, 74
•/ Frdln! 1945 16 353
’ Df>f!cpmenta! DLi^nosl* 1947 New York p 215
*J Fedut 24 148
* Aner J Dls ChUd 1950 79 931
Arier J Obstet Cyrfc 1943 45 183
Proe Mayo Clin 19^ 25 11
1 Pediatrics 1950 6 229
/ Obsiet 1941 42,686
^^Arch Dls Childh 1950 25 351
Ar-et J Obstet Cyi-ec^ 1931 21 537
in which anoxia had occurred m 132 cases was
therefore a selected one Those who had had lesser
degrees of asphyxia were hyperactive and hyperexcit
able those in whom the asphyxia had been more
severe were apathetic and readily lost emotional
control Convulsions occurred m 28% of all these
patients The intelligence quotient was withm nor-
mal limits m 74% The children tended to lack
concentration to be difficult to disciphne to play
badly with others and to be 'slow to learn from
experience Gesell and Amatruda" earned out a
different form of investigation In the course of
their developmental exammations they picked out a
group of infants with shght abnormalities m the
pattern of movement, and with clumsiness and
mcoordmation m finer manipulation They were apt
to have hyperactive reflexes an exaggerated re-
sponse to noise early speech difficulties and per-
sonality deviations All recovered completely without
sequelae They asenbed this to mimmal buth mjury
arguing quite nghtly that the history of normal
delivery by no means excludes the possibility of birth
injury and asphyxia
A much more satisfactory method of observation
IS a longitudmal study from bnth onwards of chil
dren who were known to have suffered asphyxia at
birth Darke’ watched the development of 19 chil
dren who had severe asphyxia at birth and compared
their IQ with that of siblings or parents Theu:
mean I Q was 88 and that of the controls was 100
Two of the 19 children had a higher I Q than the
controls Stevenson and Stuart’ kept under observa
tion 226 children who were in a poor physical con
dition at birth as a Tesult of asphyxia prolonged
labour prematurity or maternal toxaemia They
found a highly sigmficant relationship between this
poor physical condition and childhood maladjust
-nent In ammal expenments Wmdle and Becker”
submitted pregnant gumea pigs to the effect of
asphyxia The offspnng showed not only vanous
motor disorders but such deviations from normal
as feeding difficulties and unusual quiescence histo
logical changes m the brain were demonstrated m
65% of the ammals at necropsy Different results
were reported by Keith and Norval ” who followed
216 children bom after prolonged labour One hun
dred and eleven had asphyxia hvida or pallida or
delayed respiration for more than a minute There
were more deaths among the asphyxiated mfants m
the newborn penod than among the controls but
those who survived developed normally over a four-
year period Even severe asphyxia with delay of
several minutes m the onset of respiration did not
seem to have any effect on the survivors The
same authors desenbed then results m more detail
24 Jan 6, 1951
PROGNOSIS or FOETAL ASPHYXIA
Bumni
MeotCAL Jovanal
m another paper *" Twenty four out of 25 full term
babies who begin breathing after a delay of 1-5
minutes 15 out of 16 who began after 6-10 minutes
and all five who began after 11-15 minutes were
normal at the age of 1 year and remained so Simt
larly, McPhail and Hill \sho tested the intclli
genee and behaviour of 34 children of school age
who had been apnocic at birth, found no ibnor-
mahties among them
Finally an informative report has just appeared
from Belfast Where Campbell Chccscman and Kil-
patrick'* examined the records of the Royal Miter
mty Hospital m that city for the years 1938-41 and
selected for study all the infants who had been born
m a condition of asphyxia pallida or asphyxia lividi
lasting for a stated period of over two minutes In
the end they were able to trace 61 out of 89 " asphyxi
ated” infants and to compare them with i control
group of 134 infants bom at the same time The
examination of the children was so arranged that the
clinicians did not know from which group a child
came The authors found no significant difTcrcnccs
in the average physical measurements of the two
groups of children in haemoglobin levels or in intelli-
gence (assessed from Raven s matrices) They con
elude that the results of tlicir investigation do not sup
port the hypothesis that asphyxia neonatorum is a
common cause of later physical or mental retardation
There are great difficulties in the interpretation of
these reports It seems clear that those who are con
suited about defective children arc apt to obtain a
too pessimistic view of the outcome of foetal
asphyxia There can be little doubt that asphyxia
can and docs cause spasticity convulsions and
mental deficiency but it is not clear how often
It does so and it is still less clear whether it leads
to behaviour disorders A mentally or physically
defective child is more likely to develop psychologi-
cal disorders than other children and any study
designed to determine the relation of asphyxia at
birth to subsequent behaviour disorders should ex
-■ elude such defective children A special difficulty
IS the absence of a yardstick by which to measure
behaviour disorders Behaviour which some would
consider abnormal others with greater knowledge
of normal child psychology would Consider normal
A child s behaviour depends largely on his inherited
character and on environment in particular the
parental attitudes and management and this might
be related to the cncumstances of his birth Elderly
pnmiparae are more likely to have obstetrical diffi
culties than others and the emotional background
of an only child of elderly parents particularly if
there were seveye obstetneal difficulties or other
I ^ factors which might render another pregnancy
impossible could well lead to ovcrprotcction and
behaviour disorders A further possibility is that a
child may be cyanotic at birth because of cerebral
agenesis with its widespread cficcts on the nervous
system so that the subsequent defects need not be
the result of the asphyxia at all
Tlic answer to some of these problems can comt
only from the study of larger senes of cases but
here again there arc difficulties Tlic higher the stan
dard of obstetrics the lower is the incidence of foetal
asphyxia Darke could find only 49 cases of severe
asphyxia out of 25 261 deliveries and only 19 of
these could be traced The investigation which must
be adequately controlled should include a standard
method of measuring the degree of asphyxia such
as that of FI igg '* Tlic development of the infani
should be assessed by Gcsdl s standards and by the
other accepted methods at later ages The psycho
logical examination should be undertaken by a physi
cian or psychologist who is thoroughly conversant
with normal child psychology and who docs not
Inow the birth history of the children whom he is
examining The results of such studies might do
much to lessen the widespread pessimism about the
outlook for these children and they would ccrtainlv
help doctors to give a sounder opinion to tlic parents
RFGUrATION OF BODY TEMPCRATURI
The war gave great impetus to research on the rcla
tion of man to his working environment and mans
of the observations have added to our store of bio
logic il knowledge Much attention has been given
to the effects of changes in the environmental tern
perature on the body temperature and Glaser' ’ has
recently reported the results of some of this work
When lightly clad men were subjected to an environ
mental temperature of 0° C for 14 hours the rectal
and skin temperatures decreased The rectal tern
perature fell steadily to about 1 ° C below the initial
level As might be expected the reduction in skin
temperature as measured on the forehead and on
the hand was much more marked though the course
of the temperature change and the amount of the fall
were different in the two skin areas Tlic forehead
temperature decreased rapidly dunng the first 15
minutes then more slowly, until after 30 minutes
It remained fairlv constant at an average of 4° C
below the original reading The hand temperature
however did not reach a steady value but fell pro
grcssively by about 11 C After the 14 hour period
of cooling the subjects were allowed cither to rest at
room temperature (17° C) to do alternate periods
of exercise and rest at room temperature or to rest
in a warm room (30° C) Again the temperature
Jan 6, 1951
REGULATION OF BODY TEMPERATURE
Brniai
Medical Joukkal
25
pattern vaned between the different regions The
rectal temperature surprisingly continued to fall for
about 15 mmutes and then gradually rose over a
period of one hour when it became stable The level
at which It became stable however was always below
the readmg taken before coolmg and m the case of
those subjects who had rested at room temperature
was actually below the last reading in the cold On
the other hand the forehead and the hand tempera-
tures immediately began to increase rapidly and within
li hours settled down either distinctly above the first
observation of the day if the subject sat in a wann
environment or' regained the pre experunental level
if the subject remained at room temperature
In general the results show that the rectal and skin
temperatures become fanly constant after about IJ
hours warming At this point it is presumed that a
balance has been struck between heat production and
heat loss though the body temperature as measured
in the rectum was not restored This seems to mdi
cate that the establishment of thermal balance takes
precedence over the maintenance of a constant body
temperature If this is generally true then perhaps
the statement that man has efficient mechanisms to
mamtain a constant temperature should be modified
to read that he has efficient mechanisms for the mam
tenance of thermal balance It is interesting to note
that all of Glaser’s subjects felt comfortable within
30 minutes of leaving the cold— some time before
heat balance had been achieved — and they often had
no sensation of cold even with a rectal temperature
lower than that at which they had shivered or felt
cold before It is thus apparent that the sensation
of warmth must be differentiated from the total heat
content of the body For instance, a person may feel
warm when the body temperature is falling provided
that the skin temperature is such as to arouse a sensa-
tion of warmth in the skin and in reverse a person
m thermal balance may feel cold because of a low
skin temperature Glaser therefore concludes that a
satisfactory state of body temperature depends on
balance or near balance between heat production and
heat loss and a range of skin temperature which is
t
since there is no evidence that receptors which mitiate
shivering he in the w all of the rectum The sweating
that occuned during warming was not related to the
attamment of any particular rectal temperature
sometunes it occurred at a lower rectal tempera
ture than that at which the subject began to shiver
on the same day
The unexpected findmg that rectal temperature falls
imtially during warming may be due to the peripheral
vasodilatation that occurs immediately on entermg a
warm environment mcreasing heat loss at the expense
of deeper tissues Another suggestion made by Glaser
appears unlikely — that the temperature m the rectum
may be affected by the temperature or quantity of
blood returning from the lower hmbs through the
haemorrhoidal venous plexus to the infenor mesen
teric vem The only connexions described are
anastomoses between the vems of the buttock and
the rectal veins The rest of the blood returning from
the lower hmbs could perhaps affect the temperature
of the blood in the rectum indirectly by cooling the
blood in the iliac arteries Glaser also points out that
vanous parts of the body may change then" tempera
ture within comparatively wide limits vvhile the body
as a whole remains in a state of thermal balance or
achieves a balance at a new level and he suggests that
the balance is maintained by the appropnate move
ment of blood between the periphery and the mtemal
organs Previous work’ ’ has shown that the reduc
tion of penpheral blood flow which is a consequence
of cooling IS accompanied by an increased intra
abdominal and cerebral blood flow and that the oppo
site happens as a result of warming It has also been
suggested that blood may be diverted from the pen
phery to the lungs and vice versa dunng the redistri
bution process ' In another paper Glaser’ has demon
strated that in a cold environment the vital capacity
of the lungs is decreased as well as the volume of the
arm and in a hot environment both are increased It
seems reasonable to suppose that the cooling resulted
in “movement’ of blood from the hmbs to the
lungs so reducing the vital capacity while warming
caused movement in the reverse direction with an
subjcctivclv comfortable He found no relationship
between rectal temperature and shivenng or sweating.
Shivenng did not appear to depend on a fall of the
rectal or the skin temperatures to any particular
level It usuallv began J-t hour after cooling had
commenced and its onset slowed down the fall of
rectal temperature or even caused a slight nse due no
doubt to increased metabolism The rectal tempera-
ture at which shivenng began vaned from subject to
subject and m anv one mdiv idual from time to time
As Glaser points ouL a relationship between rectal
temperature and shivenng appears highly improbable
increase m the vital capacity Further evidence of
this redistribution has been given by Grayson * vvho
has shown as a result of a study of the temperature
of the intestine exposed by colostomy or ileostomy
that within certain limits cooling causes an increased
intestinal blood flow as well as a reduced penpheral
blood flow and that wa rming has the opposite effect
Phrtio! Lend 1940 io1 356
• \ot f la T>d 1950 166 1068
•MOlIer O Titrh A ch kl’n Med 1905 8 2 547
g and S eVcL R Z exp Path Thee |907 4
- fj: E Sammt \^-\QUnaere ^fed 194-1961
26 Jan 6. 1951
CHOREA
Bumsii
MnWCAL JOCRJUl.
CnOREA
It cinnol be Slid that we know much more about chorea
than did our grandfithcrs It remains i pu7?lc that a
disease apparcnilj doc to a profound disturbance of the
central nertous s>stcm should fail to show histological
changes in the ncrious sislcm and should lease no per
manent neurologic il defects Nor it the nnlurc of the
conncMon between chorea ind rheumatism >ct under
stood A recent stud> from Scandinasia seeks once
more to shed light on this Lewis Jonsson' sur\c>cd
all eases of chorea known to ha\c occurred o\cr a
35-ycar period from 1910 to 19-14 in i countj in the
south of Sweden Out of 704 choreic patients whose
fate was partly known there were 467 cases which at
one time or another showed rheumatic signs— poly
arthritis cirditis, erythema annulare or nodules In
22 eases the chorea was deemed secondary to another
disease such as hemiplegia, cerebral neoplasm, encepha
Iitis, or Huntingtons familiil chorea There remained
215 ciscs of crvptogenctic chorea
Analysis of the 467 cises of rheumatic chorea gase
similar results to those reported by other authors
females were more than twice as common as males
the age of the youngest patient was 3 years and most
eases came within the 6-14 ycirs age group the onset
was more often between Nos ember and M ly than at
I other times of the scar, the seasonal incideiicc following
a similar trend to that of rheumatic feser in the same
region In the group of patients with chorea of
unexplained origin the seasonal incidence and the age
of those alTccted sscro much the same as in the group
of rheumatic choreics, and Lewis Jonsson concludes that
most of these eases arc due to monosymptomatic rheu
made infection This view is supported by the fact
that the proportion of those who arc found to develop
rheumatism rises as the period of observation is
lengthened Thus Sutton and Dodge- found that, of
91 cases of initially uncomplicated chorea, heart disease
was present in 10% after 3 years, in 15% after 6 years,
and in 40% after 10 years Nevertheless there remains
a large proportion of patients probably over 50% who
never develop any other form of rheumatism
If a patient has chorea with no past or present cvi
dence of rheumatism, is it possible to tell whether or
not he will eventually develop rheumatism ? According
to Kagan and his colleagues^ ■■ the erythrocyte scdimcn
tation rate enables this to be done, for after observing
165 patients with chorea they concluded that a normal
E S R during a first attack indicated that rheumatism
was not the cause However, this conclusion is at van
ance with that of Lewis Jonsson, who found a normal
ESR in nearly half of a series of 150 eases of rheu
matic chorea The experience of most clinicians is that
if the ESR is raised m chorea then some other rheu
matic sign such as carditis, is usually present but that
in uncomplicated chorea, even it the patient later
develops rheumatism, the E S R is usually normal Evi
dently the factor in rheumatic infection which causes
a raised ESR is not the same as that vvhich gives
rise to choreic symptoms Chorea is a well recognized
complication of pregnancy These patients arc older
thin the average choreic, and the disorder tends to tike
a severe form, but in other respects it docs not differ
from ordin irv chorea In particular, rheumatism is
equally common, and in 7 out of 18 pregnant choreic
piticnts in I cw 15 Jonsson s scries rheumatic infection
hid preceded the chorea The pirt played in chorea
by emotion il disturb incc is another problematic feature
I his IS present to some dcgrec,in most eases, while in
a minority the disease seems to have followed directly
upon some mental trauma This occurred in 59 of the
215 ciscs of rheum itic chorea in Lewis Jonsson s senes
As an iltcrnalivc to this authors view that uncompli
cited chorea is monosymptomatic rheumatism, chorea
might perhaps be regarded as a psychosomatic symptom
vvhich rheumatic subjects arc peculiarly liable to develop
and which can be provoked by a vnnety of stresses—
cmoiional, metabolic, or infective the commonest infec
five factor being rheumatic fever itself
TTie facts known about this disease provide some basis
for Its treatment Clinical ciidcncc of active rheu
niatism, such as carditis, will of course mean that the
patient needs rest in bed in Us absence strict pnv steal
rest will not necessarily be indicated though hospital
care, with or without full bed rest, may well have a part
to play in helping the child to overcome its disorder It
is dilTicult for the patient s family to maintain that he ilthy
neglect of the mam symptom vvhich may be an essential
part of treatment Mild sedation apart drugs have no
part in treatment while the little use that is now made
of pvrothcnpy — whether by the use of protein shock
nirvanol, or the ' hot box — indicates the me/Tcctive
ness of such methods
FATAL iNrrsnriNAi onsiRUCmoN
There has been a steady fall in the mortahtv rate of
intestinal obstruction treated surgically In one senes
of eases in which the obstruction was iiiicomplicatcvl by
strangiil ition or circinoma the mortality was as low as
1%,' but in another senes in which gangrenous bowel
was found at operation over half the patients died"
Ncmir and his colleagues’ have tried to find out vvhy
the presence of strangulated gut should have such an
adverse elTcct By surgical means' they induced total
obstruction in dogs, with strangulation of part of the
small intestine After the animals had recovered from
the anaesthesia it was possible to give continuous intra
venous infusions as they walked about the cage Two
different types of fiiiid were found to be extruded bv
the strangulated gut A pink fluid came off the pen
loncal surface large quantities might collect within the
peritoneal cavity, and death occurred from oligacmic
shock When this loss of fluid was counteracted by
intravenous infusion, death was postponed for only a
few hours The animals died suddenly soon after the
first appearance in the blood of another pigment vvhich
was also found in the black fluid secreted within the
lumen of the strangulated gut It appeared that as soon
JElIason E L and Welly R F Ann Stirg 19-17 125 57
■Schllckc C 1 Uari,en 1 A and Dixon C r Z Amer mrti Ass
1940 116 1411
‘Ann Sting 1949 130 857 874
Jan 6, 1951
FATAL INTESTINAL OBSTRUCTION
BRITTST!
MrOlCAL JoUKNAL
27
as this fluid left the gut and was absorbed into the
general circulation, where it could be identified spectro
sco^ically, the animal collapsed and died Separate
experiments showed that the pink fluid from the external
surface of the gut was non toxic to normal dogs, whereas
the dark fluid was \ery toxic The authors point out
that the black pigment is useful only for identifying this
particular exudate, and they do not assume that the pig
ment itself is toxic Although cultures were made and
were positive for a number of organisms, they do not
discuss the possibility that the factor responsible for
death might be bacterial in origin It would be interest-
ing to repeat the experiments in dogs that have been
given large quantities of penicillin Although the toxic
factor remains unidentified, its source seems to have
been established Further support is given — if, indeed
any is needed — for early surgery but it also behoves the
surgeon to handle the strangulated gut with care to
prevent any further dissemination of its poisonous
contents
ACTH TREATMENT OF ACUTE RHEUMATISM
The interest aroused by the successful treatment of rheu
matoid arthritis with cortisone and pituitary adreno
corticotropic hormone (ACTH) has perhaps rather
overshadowed the claim first made bv Hench Kendall,
Slocumb, and Policy* that cortisone also favourably
influenced acute rheumatism If some method of treat-
ment could be found which effectively arrested the course
of acute rheumatism and rheumatic heart disease it
would be not only of profound interest in the study of
the disease but of inestimable value in eliminating an
unportant cause of death among young people A valu
able report on the effect of A C T H on rheumatic fever
and rheumatic carditis has come from Massell and his
colleagues" in Boston They studied 10 patients aged
from 7 to 21 who between them showed most of the
clinical manifestations of rheumatic fever The first
case reported is perhaps the most impressive This was
a girl aged 1 1 admitted to hospital about a month after
the onset of acute polyarthritis She was severely ill,
with a pericardial friction rub and extensive sub
cutaneous nodules — in fact she belonged to that group
of patients who are nearly always left on recovery with
a severe cardiac lesion She received ACTH for 51
days in doses diminishing from 36 mg to 2 mg daily
Fever and joint pain disappeared in 24 hours and the
pericardial friction in three davs Mitral and aortic
murmurs could then be heard Improvement however
continued and at the end of the treatment her heart was
normal clinicallv, clectrocardiographically and radio
logicallv In the other cases the response was less
dramatic Reporting on the results obtained with cor-
Usone or ACTH in II cases of acute rheumatic fever,
Hench and his colleagues’ state that it will talc months
or vears to determine whether these hormones will pre
vent the initial development or aggravation of rheumatic
carditis
It IS important to remember that patients with rheu
matic fever as ill as the first child can make, though
V Fmc Vf ls> €!•- IS-S tt TH
» \r» £>r( 4 V lOSO SU, MI ted
* A <■* < 's-r Vfri 19S0 tS S4S
rarely , a complete clinical recovery From these 10 cases
It IS clear that ACTH will control the fever and the
arthritis of acute rheumatism in 24-4S hours, but so
also will salicylates The diflicultv is notorious of assess
ing the effect of any form of treatment in acute rheu
matism which in different patients runs such a varving
course The only patient with chorea treated by Massell
and his colleagues improved immediately, but choreic
movements persisted for 30 days Subcutaneous nodules
were observed in three children under treatment, thev
remained present for 45 and 50 days in two and were
still present at the time the report was written in the third
The sedimentation rate, too remained raised for any
thing from 6 to 87 days On withdrawal of the drug
there was a return in some cases of fever and joint pain,
which cleared up again when an increased dose of the
drug was given This phenomenon is of course well
knovvn during salicylate treatment The tendency of
ACTH to cause retention of fluids sometimes led to
an exacerbation of congestive heart failure this, how
ever, could be controlled by diuretics and restricted salt
intake Side effects of the hormone treatment included
the development of acne m six cases, roundness of the
face m six cases, and striae in two
From these studies it appears that stimulation of the
adrenal cortex by ACTH can certainly benefit acute
rheumatism, though of course this does not necessarily
mean that an endocrine defect is concerned in the aetio
logy It IS not clear from the report of the Boston '
workers whether ACTH arrests the rheumatic pro-
cess or whether it merely controls some of the clinical
manifestations of the disease Many consider that the
latter is all that can be claimed for salicylates While
the effect of A C T H on acute rheumatism is of very
great importance m the study of the disease, it may in
the end prove to be comparable to that of salicvlates
SMALLPOX EProEMIC
Eleven cases of smallpox including one death, had
been reported in the Bnghton area up to January 1
(6pm) (see page 48) The usual precautions are being
taken to stop tlie spread of the disease, but cases
may appear elsewhere, especially among people who
have been m direct or indirect contact with the RAF
officer who introduced the infection from Karachi In
December this man made three tram journeys between
R-A F stations in Scotland and Brighton Doctors
throughout Britain should therefore bear in mind the
possibihtv that smallpox may occur in patients unaware
of any contact with a suspected case Notable features
of this epidemic arc the lack of diagnostic signs and
symptoms in the initial case with consequent late diag
nosis, and the spread of infection to laundry workers
bv means of contaminated clothing
We record with regret the death on December 30 of
Mr G R Girdlcstone, who had an international repu
tation as an orthopaedic surgeon and was Nuffield
Professor of Orthojaaedic Surgery m the University oL-
Oxford from 1937 to 1940 He was 69 years of ''
' 28 Jan 6, 1951
FUNGUS INFECIIONS OF mc SKIN
^ fJxnnn
Mcmcxt JounMAi
REFRESHER COURSE FOR GENERAL PRACTITIONERS
FUNGUS INFECTIONS OF THE SKIN
> in
r RAY RETTLEV, TD, MD, ERCF
Physician lor Di^casci oj the Skin StulJlcit\ Uoipiliil London
Most fungus infections of the skin insolvc onlj the
epidermis nnd Us appcndigts, the hiir ind the mils
with compintisely little reiction of the underKing
tissues For this reason they arc not a \crj potent
cause of serious disability except when comphcitiuns
arise Their increasing prcsalencc, howeser, gives this
group of infections import mcc 1 propose to deii with
them in roughiv their order of frequency in this country
at the present time
Tinea Pedis
This occurs in two very ditferent clinical forms which
are, however, often associated together cither simiil
tancously or at different times in the same patient The
vesicular form nearly always starts in the centre of the
sole, under the arch of the foot as i group of perhaps
half a dozen watery vcsjcles of large pin head size which
after a few days become superficial pustules At this
stage irritation may be considerable but the thickness
of the corneous layer is usually suflicient to keep the
vesicles intact in spite of scratching
The pustules gradually dry up and as they do so
take on a brownish colour so that they arc eventually
shed in the form of thicl brown scales a quarter of an
inch or so across It is a week or ten days before these
scales are formed, and by this time fresh vesicles arc
often forming near by This process may continue for
some wiccks, eventually appearing on the sides of
the feet and toes and even on the dorsum of the foot
Even without treatment however the process eventu-
ally seems to burn itself out and the attack subsides
for a time
The interdigital form develops more insidiously and
may consist of no more than a maceration of the skin
between the fourth and fifth toes, which the patient
attributes to moisture The eruption is usually a little
more extensive, affecting the under surfaces of the fourth
and fifth toes and the skin between the third and fourth
toes as well Thick white sodden scales are formed and,
with any unaccustomed walking, painful fissures arc
likely to appear between and under the affected toes
Once this interdigital form of ringworm starts it seems
to continue almost indefinitely and probably forms a
reservoir of infection from which attacks of vesicular
ringworm on the sole periodically originate
A generation or so ago this kind of ringworm was
chiefly to be found in the Tropics and was spread in
this country in the public schools and sports clubs It
has now become so widespread that the name athlete s
foot IS no longer merited Dr Jacqueline Walker
has recorded that National Service men on entry to the
Army showed a 3 8% incidence of foot ringworm
The diagnosis is not always easy and T believe that the
clinical appearances of both types of the disease may be
mimicked by other affections For this reason it is most
dcsiriblc to cvaminc scrapings before treatment iv
St irttd s(j th It the di ignosis may be assured All too
often this cviminilion is left until i prclimin iry period
of tre itniLiit h is f iilcd ind the fungus m ly then be
very diflieult to find even though it was originally present
and the cause of tin trouble For this cximination a
few scales or the roof of a vesicle arc removed from
the margin of the affected area placed on a microscope
slide and flooded vviili lO” liquor potas5.ic After
five or ten minutes the prcpiration is sufficiently softened
to flitten out under pressure of thecovcrslip and is then
Skin scales showing fiinrus iinsinincd prcparalion high power
I roni a case at Ihe Middlesex Ilospilat
examined unstained with the high power objective In
an unlrc itcd case fungus is usually cisy to find after
two or three minutes search (see F igure) if it is not
found quickly it is better to take fresh scrapings rather
than to spend a long time over any individual slide
CompHcatlons
It is the complications of foot ringworm far more than
the disease itself which cause incapacity They are
Jan 6, 1951
FUNGUS INFECTIONS OF THE SKIN
BwTisn
Medicai. Jouxnal
29
nearly always due to secondary infection with pyococci
or to contact dermatitis resulting from the prolonged use
of antiseptics and fungicides
Treatment
In my experience, the old fashioned Whitfield^ oinl
ment is still as good as anything Now that coco nut
oil IS agam available the original formula can be used
R
Salicylic acid, 15 gr (1 g)
Benzoic acid, 25 gr (1 65 g )
Coco nut ot! 6 drachms (21 ml)
Soft paraffin to one ounce (30 g )
The ointment should be hberally applied twice daily and
the foot enclosed in a thin cotton sock or a single layer
of calico held in place by normal socks or stockings
In recent years a good deal of research has been
earned out into fungicides and several elegant prepara
tions are now on the market There can be no doubt
that most of them are very effective, perhaps more so
than Whitfields ointment, but most of them are more
hable to cause contact sensitivity and a severe form of
dermatitis which may be far worse than the original
disease
Three or four weeks treatment is usually sufficient,
and durmg this period the patient must be schooled to
the regimen which he should adopt if he is to tavoid
recurrence Recurrences are of course all too frequent
In some cases they seem to be definitely related to re
infection by wall ing bare foot in a club changing room
or hotel bathroom It is known that the organism may
remain for months on an infected floor and that it may
survive the ordinary process of washing with soap and
warm water Once the patient has shown that he is
susceptible to this infection it is important that he
should get into the habit of never putting the bare foot
to the floor even in his own home Socks should be
sterilized either m the autoclave or by soaking for twelve
hours in 3% cresol before they are washed This period
of sock sterilization should continue for a week or so
after the skin has returned to normal Bedroom slippers
in which bare feet are placed should be either thrown
away or packed with formalin swabs and enclosed m an
airtight box for three days Shoes which are worn with
socks need not be dealt with
Sometimes there is no history of reinfection, and in
these cases attacks often seem to follow unaccustomed
exercise in which the feet have perspired more than
usual There is little doubt that excessive perspiration
predisposes to infection and it is impossible to say
whether the organism has been lying dormant in the skm
during months of quiescence or whether there is, in
addition, a fresh infection from without
It IS therefore important for the patient to avoid
those things which are apt to lead to excessive per
spiration of the feet He should wear light shoes
avoiding rubber soles and in summer open sandals are
helpful Thin cashmere socks are usually best The
feet should be washed every day with soap and water,
swabbed with industrial spirit and powdered with zinc
oxide and starch powder to which 2% of boric acid may
be added When recurrence takes place the patient
should be carefully questioned in order to ascertain if
possible why the relapse occurred A search should
also be made for ringworm infection elsewhere on the
skm particularly in the nails
Tinea Unguium
It IS my impression that ringworm of the nails has
become a good deal more common in recent years
Climcally, the most constant physical sign is separation
of the distal part of the nail from the nail bed with a
dirty yellow or orange discoloration The nail usually
becomes brittle, and may be ridged or furrowed These
changes are of course produced by the fungus growing
in the substance of the nail the nail having been origin '
ally well formed For this reason the changes of ring
worm are usually confined to the distal half of the nail
and the proximal part remains normal This is perhaps
the most useful differential diagnostic point, since most
other affections of the nails are true dystrophies and
affect the nail matrix so that the irregularity of the nail is
present from its first formation Another useful diag
nostic point is the fact that ringworm of the nail nearly
alwavs starts in one finger or toe and others arc affected
one by one at random True dystrophies often affect
all the nails simultaneously or, if they do not, are at
least symmetrical Ringworm of the nail produces no
inflammatory reaction in the soft tissues around and
no symptoms other than the ugly appearance and
awkwardness resulting from brittleness and difcolora
tion For this reason the patient will usually complain
of ringworm m a finger nail but an infected toe nail
may go unheeded, particularly if it is one of the smaller
toes
Ringworm of the natls is caused by the same organ
isms as those which may give rise to ringworm on the
feet and elsewhere on the skin An infected nail may
therefore constitute a reservoir of infection from which
tinea of the foot or groin may repeatedly develop
Although the diagnosis can often be made with
reasonable certainty on clinical grounds alone, it is
essential to nuke sure by finding the fungus before
embarking on the long and tedious treatment which is
necessary Clippings of nail and the debris beneath are
steeped in 20% liquor potassae until macerated and
examined in the same way as scales The fungus may
be difficult to find, and repeated careful search may be
necessary
Treatment ,
Sir Norman Walker referred to ringworm of the nails
as a calamity which no decent person would wish on
his worst enemy Treatment is difficult and exacting
and to most patients seems at first out of all proportion
to the severity of the disease It must be pointed out,
however, and the patient must understand, that with half
measures the affected nails will never clear up , they will
remain a source of infection for the rest of the skin
and, as the years pass, more finger and toe nails are
likely to be involved The great difficulty in treatment
arises because the fungus grows m the substance of the
nail, the solid tissues of which protect the micro
organism from fungicides X-ray {reatmfent is without
effect The problem therefore, is to remove the infected
nail and thus to expose the fungus to attack with anti
sepfics
Conservative treatment consists in cutting away the
separated nail as far as possible with pointed scissors
The nail plate must then be systematically scraped as
thin as can be borne the best instrument for the purpose
is a piece of broken glass of suitable size and the
30 Jan 6, 1951
J UNGUS INFLCTJONS OV IJIL SKIN
nwitsH
MOtCAl. jOUKSAl
scraping should occupj at least ten minutes uscry diy
After the patient Ins scripcd away as much as he cm
bear, a suitable application is 1 2 000 pcrchloridt of
mercury in 50^', spirit This treatment needs to be
continued for two or three months It is i treatment
which requires a grcit deal of determination and perse-
verance on the part of the patient It is seldom possible
to carry it out properly on any toe nail c\ccpt that of
the big toe and, since it is time consuming, it is not
likely to be successful if more than one or too nails are
affected Tor these reasons I adsisc conscrsatisc treat
menl with iny confidence onl> for an intelligent \dult
with one or two finger nails affected
The alternatisc is remos il of the affected nails In
this waj the bulk of the inaccessible fungus is remosed
but it must be remembered that tlie organism reni iins
on the nail bed and will infect the new nail if it is not
dealt with The affected nails arc therefore asulsed
under local or general anaesthesia and the nail bed
lightls curetted to remove debris A drcssing~of tulle
gras ma> then be applied and need not be changed for
a feu dajs After four or five dajs the tenderness of
the nail bed rapidlv diminishes and the area may then
be dressed with Whitfields ointment twice daily In
the CISC of toenails, rest in bed will be necessary for
a few days, but normal shoes can usualls be worn after
a sscek or so Fingers must be kept covered with a
finger stall, preferably of leather it is not satisfactorv
for a rubber glove or finger stall to be worn for long
periods Treatment with Whitfields ointment should
continue for two or three months bv which time the
new nail will be growing up
Even this drastic treitment with its upset of the
normal life of the patient, is not alw lys successful and
It should be explained to the patient at the outset that,
although this method is far more satisfactory than
conservative treatment there is nevertheless a substan
tial risk of recurrence If this occurs the more drastic
step of excision of the nail matrix may be considered
On the toes, particularly the small toes this involves
little disfigurement but many patients do not like the
idea However, the permanent loss of toe nails con
stitufes no disability, and excision of the n ul bed is
probably wise in recurrent tinea of toe nails if finger
nails are not already affecled Permanent removal of
finger nails constitutes as much disfigurement as tinea
and some degree of disability as well For this reason
£ would advise repeated avulsion of finger nails if
necessary rather than complete excision
Tinea Tonsurans
Had this article been written four or five years ago
scalp ringworm would have taken first place It became
very common during the war but as soon as more
normal conditions were restored and treatment could be
better organized, the disease was brought under control
U is now comparatively uncommon The clinical prob
lem has been epitomized by Darier “ Any multiple
scaly patches or dry eczema localized to the scalp m
children impose the need for a meticulous search for
broken hairs
This type of ringworm is very seldom seen in adolcs
cents or adults and affects principally children, espe
cially boys between the ages of 5 and 10 The
well outlined scaly patches are not truly bald, since
the hairs do not fall out by the roots but snap off.
leivmg the affected area covered with stumps While
this IS the eh ir ictcrivlic picture, some patients present
no more th in a scaling patch .ind the hairs do not seem
to become bniile In nearly ,ill types of scalp ring
worm the nffccled hairs fluoresce in ultra violet light
this IS best seen with a mercury vapour lamp screened
with Woods glass which cuts off most of the visible
nys When this is shone on an affected scalp in a
dartened room individual hiirs containing the fungus
shine conspicuoitslv with a green fluorescence In this
Way an infected child can be picked out in i few
moments examination, and even single infected hairs
can be found at a stage when the disease could not
be clinic illv diagnosed I or this reason a lamp to pro
vide Woods light IS essential for the examination of
contacts, the prevention of epidemics and the detcc
tion of rehpscs Ihc fluorescence produced by soft
paraffin should be carcfiillv distinguished it is of a blue
colour, and of course can be removed by cleaning the
hair with ether
Characteristic fluorescence with Woods light is pallio
(.twmonic In cases of doubt or if W'ood s light is nol
vvaihbic the diagnosis of ringworm should be con
lirmcd by examining a hair m the same way as scales
Ihc fungus appears as a close mosaic of regular
rounded spores encircling the hair shaft A proportion
t>f ciscs of scalp ringworm arc due to the organism of
cat or dog ringworm Unlike ringworm of the human
type these ciscs seldom occur in epidemics since the
infection does not rcadilv p iss from one human to
mother The distinction cm be made with certainty
only bv culturing the organism
Trralnirnt
Hie treatment of rmiworm of the scalp presents a
problem similar to tint of ringworm of the nails The
orginism is protected bv the relatively impervious
m itcri il — in this ease the hair shaft — m which it grovss
The starch for a fungicide and for a vehicle which
would penctrite into the bur shift was being activelv
pursued in this country a vear or two ago Now, how
ever, the disease has become comparativclv rare, and it
seems as though these researches arc hkclv to come to a
standstill Since, up to now no certain vv ly of reaching
the fungus has been found successful treatment depends
on the removal of the infected hairs Tliey cannot be
removed manually, since thev arc brittle and break off
and the only successful method which has stood the test
of time IS epilation with r rays W'hcn earned out
by an experienced operator this procedure is absohitclv
safe The hair usually f ills from the whole of the scalp
about a couple of weeks after the t mvs have been given
and gradually grows again after a further lapse of three
or four weeks \ rays have no effect on the fungus
itself and during the period of baldness Whitfield s
ointment should be rubbed into the whole of the scalp
twice daily
This may seem a drastic treatment, but parents should
be urged to adopt it without delay conservative treat
ment IS exacting time consuming and most uncertain
m Its results
A child with scalp ringworm should so far as possible
be isolated from onVr children until after x ray epilation
IS complete Throughout this period he should wear a
washable linen cap m order to minimize the spread of
infection The detection of a ease of ringworm imposes
Jan 6 , 1951
FUNGUS INFECTIONS OF THE SKIN
the need of routine examination of his brothers and
sisters, playmates, and schoolfellows For this purpose
Woods light IS indispensable
Tinea Cnins
This IS usually caused by organisms which may also
infect the feet or the nails Known as dhobie itch.
It was formerly chiefly farmliar as a tropical infection
contracted by wearing clothing which had been infected
during laundering The eruption appears as a bright
red Itchy disk on the inner aspect of the thigh two or
three inches below the crutch The affected area is
scaly and sometimes there are a few tiny vesicles at the
margin , very often the margm is a little raised and
palpable, with a tendency for the patch to clear up
spontaneously in the centre As the patch enlarges it
extends to the inguinal region, thigh penneum or
scrotum In differential diagnosis this form of ringworm
IS to be distinguished from intertrigo the latter always
starts exactly in the groin fold and not a few inches
down on the thigh . Extending from the fold it usually
affects opposing surfaces symmetrically At the margin
of a. patch of tatcrtrtgo fofficafat fcstoas ate very oftett
to be seen tinea of the thigh is never follicular Unless
the clmical diagnosis is quite certain it is always best
to remove a scale, preferably from the margin of the
patch, and examine it microscopically The fungus is
easy to find
Treatment
This form of ringworm responds well to treatment
Whitfields ointment may be rubbed into the affected
patch twice daily for a fortnight or three weeks, and
seldom fads Recurrences are not very unusual and are
probably most often due to a reservoir of infection on
the feet or nails In order to avoid reinfection from
clothing underwear should be boiled during the period
of treatment
Pitynasis Versicolor
It IS difficult to say how common this type of ring
worm IS , very often it is found on patients who are
being examined for another purpose, and although some
patients complain of slight irritation, many people do
not notice its presence The eruption appears pnnci
pally on the back and front of the trunk and is made
up of patches or sheets of a faint fawn or brownish
colour It IS usually only when the patches are scraped
that a fine adherent branny scaling becomes evident
The patches are well outlined, but there is no erythema
or other alteration of the skin When scales are_
examined microscopically fine filaments of fungus can
be seen together with clusters of spores
From the absence of any inflammatory change it is
cleat that this infection is extremely superficial Symp
toms are negligible and it is not easy to persuade
patients to use messv ointments over a wide area of the
body for such a trivial complaint, since there are indeed
no complications Because of this I usually give a
lotion consisting of 50% spirit containing 1 2 000
mercury perchloride to be swabbed over th^ affected
areas twice daily Underclothes should be boilTd dufing
the period of treatment In practice the eruption s
rather resistant to treatment, and shows a strong ten
dcncy to relapse I suspect this is largely because it is
so difficult to ensure that treatment is effectively earned
out
BRmsa "31
Medical Jouwial
LORD BORDER 80
Lord Herder who is 80 years old on January 7 can look
back on a life of unrivalled service to the profession and
\Vit public StiW Wvmg ttit pbysicat encigy and mental
alertness of a man many years younger than himself he can
too look forward to giving — and we to receiving — many
years of active and pertinent counsel in all those various
aspects of hfe and medicine which have engaged and held
his unflagging interest As was said of him in the Sunday
Tunes a year ago TTie societies of which he is either presi
dent or chairman are mainly those which support the right of
an individual to decide for himself those matters which con
cem only himself Some men prominent in public life come
to assume a public mask When on the public stage they
play a part which has been carefully studied and rehearsed
But Lord Horder on public and private occasions has
always been himself forthngbt and direct in speech that at
times has the precise sharpness of the etchers tool He
has been and is an individualist in the best meaning of this
word It IS surely this added to his brilliant qualities of
mind and unusual capacity to observe what he sees which
has made him the supreme clinician of his day It was an
almost uncanny observation that led him to supply a criti
cal piece of evidence when he was called in during one of
the illnesses of Edward VII
It IS just over forty years ago that Dr Thomas Horder
(as he then was) published his classical description of sub
acute bacterial endocarditis He was the first to isolate a
streptococcus from the blood in this disease and establish
it as an infective condition This was the fruitful outcome
of his early awareness of the importance of clinical
pathology the subject of his first published book in 1910
In the early years of his consulting practice he did his
own pathology with the help of what came to be known as
Holder s box containing test tubes culture lubes blood
counting apparatus and a blood culture syringe He brought
clinical pathology to the bedside at a time when too many
were content to bring only the bedside manner Lord
Borders clinical exemplar was that great Barts physician
and teacher to whom he was house physician Samuel Gee
and part s holds in grateful memory Gee s house physician
who in the course of time also became a great physician and
teacher in an institution which for over 800 years has been
an active witness to the continuity of medical history _
The International Hospital Federations Nens Biillelin
reports some differences from Bntish practice noted in a
tour of Swedish hospitals Bedpans are never sterilized a
good dousing in cold water being considered sufficient
Creeping plants in pots and boxes are often trained up the
inside walls of wards and hospital rooms the patients like
It and doctors and nurses see no harm in it
32 Jan 6, 1951
MEDICAL NEW YEAR HONOURS
Dumtii
Medical Jo< rsal
MEDICAL NEW YEAR HONOURS
The mmcs of the follouint members of the mcdicnl profes
Sion were included in the New Ycir Honours I iM published
in the London Gazette on Janu ir> 1
KC VO
Damel Thomas Davies CVO MD f R C I* rh>Mcnn
to the kine
Trancis Hugo Tcall CVO MD IRC I* Honor*ir>
O/Ticer in clnri.c of Imrnunoihcnp> Depirimenl Uni\er5il>
College Hospinl London
K U C (Ci\tt Dixislott)
Percy Selwvn ScLwvN Clarke CMC C MD FRCP
Go\crnor and Comnnndcr in Chief of the Scvchcllcs
Jlon KSr (Cnit Dnhion)
Tr^ancis Akanu IniAM Hon OUP MR Ch R Member
of the Executive Council Nigeria
Knlf^hthood
koFOwoROiA Adekumc Aravov!! MD Member of the
Executive Council Nigeria
Trank M^cearlane Rurmt MD Sc D PhD TRACP,
FRS Dircclor of Waller and rii?*! Ihll InMitutc Melbourne
Ausinha Tor services to biological rcseirch
W'lLLlAM kELSlYfRY COF \f C MDS TDS MRC^
LRCP Dean of the Tncuhy of Dental Surgcr> of the Royal
College of Surgeons of England
Gordon Morgan Holmes CMG CRT Hon ScD Hon
DCL MD FRCP FRS Consulting Physician Charmi
Cross Hospital and National Hospital for Nervous Diseases
London
CD (Afthtary Dhtshn)
Kcnnitth Allvandfr IscLcnv MACKEsrip BM RCh Sur
eeon Rear Admiral Honorary Physician to the king
Thovias Young ORF MB Oi B Major Genera! laic
R A M C Honorary Physician to the king
CAf G
Clifford Crato MD MS TRACS Surgeon Superin
icndent Launceston General Hospital Tasmania
V
CVO
George Proctor Middleton MVO MB Ch R Surgeon
Apothecary to His Majesty s Household at Balmoral
CBC (Afilitary DtMSinn)
VyvYVN Stewart Ewing MB Ch B , D P II Air Conimo
dore RAT
CBC (Ci\tl DiMslon)
James Boyd MD FRCPI DPH Chief Medical OfTiccr
Ministry of Health and Local Government Northern Ireland
Lucy Merfditii Bryce MB RS IRACP Honorary
Director of the Blood Transfusion Service Viciona Australia
Joseph Stanley Hopwood MB B S Medical Svipcrintcn
dent Broadmoor Institution
Peter James knRLCY MD FRCP TTR Director,
Radiological Department Westminster Hospital Consultant
Adviser on Mass Radiography Ministry of Health
Geoffrey Marshml OBE MD FRCP Principal
Medical Referee to the Civil Service Commission
kAMiL Mohamed Ariff bin Kadir Mustan LMS Tor
public services in the Federation of Malava
Advm Rankine MC mb Ch B Lilcly Colonial Medical
Service Director of Medical Services Mauriiius
Vincent Brian Wicglesworth MD FRS Director of
the Unit of Insect Physiology Agricultural Research Council
O B C (Military Division)
cSl rTm Lieutenant
ma^derRAF*'’ Ch B Acting Wing Com
OBL (Chil Dhislon)
JaM! s Tanstonl MD Physician Surjeon and Founder of
the Hospital Lvangclico Annapolis cm Goya? Esiado dc Goyaz,
Rra/il
T HOMAN Ghrav MB Ch R A medical practitioner of
Napier New 7calind
Don Sam dc Simon LRCPt^SId Medical Supcnnicn
dent leprosy Hospital IKndala Ceylon
John AiiVANiitR jAstis Ch M I RCS A pfomincnl
pliystCian and surgeon in the Australian Capital Tcrrilory
Attvandtr Camfro MckiLLoi MR Ch B of Christchurch
New Zealand for scrvitcs to psychnlry
WiitiAM Hunt Climokd Paekick MD Regional Medical
Ofliccr Ministry of Health
Mohamid At! Rana MRI M R C^S LRCP Tor public
services in kenya
Andhtw Jami s SitivNti MD DPH Medical Oniccr of
Health City of WcMinmsicr
Sisnatamtiv SurpAMANiAvt, I R C PAS Cd I or medical
and social services
At sN RontRT StANifv \icnrRs Ch M Tor services to the
flying Do-tor Service In Australia
I ION Jami s W H HAMS MD I or public <cnrcv m B-rmuda
MBl (MiUtars Dnhlon)
IfAVtitTON Jav!i s I I VERSON, n M B Cli Major (tcmnotaty)
R A M C
WiitiAVf Rovd Jack R\1 RCh Acting Interim Surgeon
Lacutensnt Commander R N
Tirenci Richard Jasmn LD LKCPAiSEd Major
Ceylon Medical Corps
Trevor Siakseipid Law MR, Ch B Surgeon I leu cnant
M BS (Chil Dnhhn)
Arihur Grhiitiis Tarr MB RChir Colonial Medical
Service Acting Senior Medical Officer Tanganyil^a
SsMUtt ItRCHsoN I toM) MU U Ch General Medical
Pracutioncr County Down
Ar Ni a Grace Gillispie MR Ch B Medical Missionan
Mary Calvert Holdsworth Memorial Hospital Mvsorc City
India
Jolts Jamir Sparks I M S British Vice Consul at Coatza
coalcos Mcvjco
I RANcts Hinrv Whitt iitad M R C^ LRCP Chairman
Wandsworth and Ratiersea War Pensions Committee
At a pathological meeting of the 1 iverpGol Medical
Institution on Tluirvchy D cember 14 Dr R C RcwcII
pathologist to the I ondon Zoo read a paper on The
Pathology of Captive Wild Animils He siid that the
size shape and metabolism of cells was limited and con
trolled by factors imlcpcndcnt of the dimensions and struc
hire of tilt whole animal Thus a granulosa ccllud tumour
of the ovary had the simc structure and might show the
same vinalions in a small monkey as m a woman or as
in a giLanlic whale However such tumours lotild bt
found only in inimals witli Graafian folhtics Variation
m the structure of organs conditioned local v irnlions in
the results produced by discise Inflimmation of the lung
of I reptile which has no closed spaces produced i condi
tion comparible to enteritis tn mammils the lung of a
bird with its through and through irrangeinent became
completely solid while the numerous blind ends i>f a
niammilian lime g'lve rise to the characteristic lobular
consohdition Differences in metabolism must be re
sponsible for such things as the high incidence of
Lacnnccs cirrhosis of the liver in the Arabian camel
not seen in the closely related Bactrian camel though
both are iisinlly on the same diet wink in a zoo Skin
bods in ungulates were due to a coryneb iclenum while
in Equidae artcriil aneurysms were caused b\ the worm
Sfrongy/ns \ufgans Some of these pathological condi
tions might be useful in the selection of suitable expen
mental animals outside the ringc of those commonly
employed
Jan 6, 1951
REPORTS OF SOCIETIES
Buttsh
Medical Journal
Reports of Societies
ROYAL SOCIETY OF MEDICINE
AETIOLOGY OF PNEUMONIA
The subject of pneumonia was discussed by the Section of
Epidemiology and State Medicine of the Royal Society of
Medicme on Friday December 15 1950
Dr W H Bradley from the chair said that the
comparative mortality index of pneumonia (all forms)
taking 1938 as 10 had been 176 in 1911-15 and
■was 0 5m 1948 There had been some fall even before
the introduction of the sulphonamides in 1935 Deaths from
all forms of pneumonia were 26 786 in 1935 and 20 792 m
1949 Notifications were 46 401 in 1935 and 34 538 in 1949
Pneumonia remained a very serious problem
Dr J G ScADDixG pointed out that it was impossible to
classify pneumonias purely on an aetiological basis Certain
pneumonias were due primarily to a breakdown of the
defences of the respiratory tract When this happened
organisms in the upper respiratory system not normally
pathogenic might gam access to the alveoli and there cause
an inflammatory reaction He therefore divided pneumonias
into two broad groups the acute specific pneumonias and
the aspiration pneumonias In the former group were
included pneumonias due to specific bacteni viruses
nckettsiae fungi plasmodia chemical substances and
allergy He also included in this group pneumonias associ
ated with viruses such as those of influenza and measles and
due to the combined action of viruses and bacteria Aspira
tion pneumonias were preceded by an upper respiratory tract
infection or by bronchitis Commonly the illness began
insidiously and respiratory symptoms were prominent in
contrast to the typical virus pneumonia in which constitu
tional symptoms predominated but it was admitted that in
many cases the clinical differentiation was difficult
Dr Scadding gave an account of aetiological studies
earned out by his group at the Postgraduate Medical School
of London since October 1949 There were 110 cases of
pneumonia He contrasted the low incidence of pneumo
coccal pneumonia (26%) in 1949-50 with the much higher
incidence (68%) at the ^ame hospital jn 1938-9 Most
pneumococcal pneumonias occurred during the winter
months but they continued sporadically during the summer
All 10 staphylococcal pneumonias were seen between
October and April There were eight cases with cold
agglutinin titres of 1 256 or above and these were all much
younger than the average age for the series there were no
constant clinical features and the cases were distributed
throughout the year There were a few cases with serological
evidence of ornithosis or Q fever The influenza B cases
occurred from January to April 1950 and were associated
with pneumococcal or staphylococcal pneumonias or with
those of undetermined aetiology In no fewer than 27 cases
which had had no chemotherapy before admission no
aetiological agent could be identified Eighteen were
scattered lobular or segmental pneumonias and most of the
patients either had had a preceding upper respiratory
tract infection or were chronic bronchitic subjects It there
fore seemed likely that some at least were essentially
aspiration pneumonias
Professor C H Stuart Harris considered that the
majonty of infections of the lung were due to bacteria but
he stressed the frequent association of pneumonia wilh
upper respiratory tract infections at all ages He had found
a fairl> close relationship between the pneumonia death rate
from season to season and the deaths in the great towns
recorded as ^ue to influenza With his colleagues he had
studied cases of pneumonia and other respiratory diseases
admitted to hospitals in Sheffield between October 1947
and April 1949 He contrasted two phases within this
penod The first phase extended from October 1947 to
December 1948 during which time only two sporadic infec
lions with influenza A virus were recorded among some 85
3 *^
cases studied Seventy seven of the cases studied had
had pneumonia and th^re were three deaths During the
Second phase from January to April 1949 there was an
epidemic of influenza A In iHTs phase 95 cases were
studied there were 70 cases of pneumonia with 16 deaths -
There was some contrast in bacteriology between the two
phases staphylococcal infections were much commoner in
the second phase Of nine cases from which influenza A
virus was recovered at necropsy the lungs were infected
With staphylococci m six During this phase serological tests
for influenza A were positive in 27 out of 57 cases of upper
respiratory tract infection in 11 of 53 cases of non fatal
pneumonia and even in four out of seven cases of
heart failure Though some cases of staphylococcal and
-influenza A infection ran a fulminating course suggest
ing a symbiotic attack by the two organisms cases of com
bined infection with pneumococci and influenza A seemed
no more ill than those infected with pneumococci alone
Dr B P Marmion discussed serological tests for influenza
cold agglutinins streptococcus MG Q fever and the psitta
cosis-omithosis groups Sera were submitted to the Central
Public Health Laboratory at Colindale from all cases of
pneumonia admitted to two large hospitals and from various
cases of respiratory infection elsewhere in the country
Between June 1949 and May 1950 24% of sera from cases
clinically diagnosed as influenza or febnle catarrh
were positive for influenza B 14% of cases of lobar
pneumonia were positive and 16% of cases of atypical
pneumonia ’ Twenty^one per cent of~cases diagnosed as
atypical pneumonia had positive cold agglutinins and
5 6% were positive for-Q fever The 26 cases serologically
diagnosed as ornithosis were evenly distributed between the
different clinical diagnoses suggesting a lack of any well
defined clinical picture Of these cases less than half had
any clear evidence of contact with pigeons chickens or
parrots ^
In this senes cases positive to serological tests for omi
thesis and Q fever were evenly distnbuted throughout the
year The influenza B cases occurred between January and
April 1950 Cases with cold agglutinins were seen at all
■ seasons hut were more frequent between December and
April positive litres for streptococcus MG occurred only
m those having significant litres of cold agglutinins _
Dr Marmion discussed the significance of the test for cold
agglutinins This lest was positive \n a high proportion of
volunteers infected by the American Commission for Acute
Respiratory Infections with filtered material from primary
atypical pneumonia It was clear therefore that the
reaction was associated with a virus infection Eaton has
brought forward good evidence m favour of his cotton rat
virus being the infecting igenl responsible but the evidence
could not yet be regarded as conclusive The position' of
streptococcus MG was uncertain It was not clear whether
the organism caused pneumonia itself or whether it was
symbiotic with a virus in the same manner as m swine
influenza or whether the streptococcus MG shared an
antigen with the causative virus
WHAT IS GENERAL PRACTICE?
The first regular meeting of the newly formed General
Practice Section of the Royal Society of Medicine was
held on December 20 1950 under the chairmanship of
Dr G F Abercrombie when there was a discussion on
What IS general practice *>
Dr G O Barber (Great Dunmow) honorary secretary
of the Section said that when the Section was bemg formed
this question was asked again and again so that it seemed
logical at the first meeting to face it and to define medicine
as practised b> the family doctor m so far as it differed
from hospital and specialist practice
He recalled an incident of 20 years ago He was a young
doctor and the old practitioner was dying \\Tule he was
in a little room combined waiting room and dispensary
behind a partition of wood and frosted glass he heard one
woman who was waiUng say to another, 1 don t think
34 Jan 6, 1951
Rcpoinsoi socintins
much of )ounp doctor nic> s\> he cxofufori people
to find otil wlnt n wnuie with them It hid tot^en turn
mnny yents to rcili/c that tint t,ood Ivdy m-w »i|ht Not
thtit one should not examine one x patientx and i cep rccottU
of them hut Mint tnil been home in upon him mi that
the }ood prittitioncr in hvine voi xnmK amour hit paticnlt
shjfinp their life in \illiic or toMii loOMtiir them and llieir
vvorh the 000(1111001 under mIikIi thci hied their piirmiti
vicei loie aflairi and io on jot xo mtinntc a hnoMleilje
of them that tonp and dctiiled e\ itninaiioni I'cani'
supcrnuotii in a mmih''r of c i ci
Tile Jiinrle and |lie /on
Tltc pencral practitioner Dr flithet nent on Mai n
natiiraliii piirminp tin (ivutry and itodyinj, ti |iiluti in
the jtinplc the ipecntiit ohictiied only the ip'a.iateiti m
the zoo To put it in another May the iiiuK of the ore
Mai !n \i\n and of the other in iliro The enenic of
peneral practice M'i ilic ittidy of nun in hn oauirjl
ennronment The ipcnaliit Mai handituppcd hy hiiinj
to taVc n one aided aniMcr to hii qiicitiom Mhereai the
pcncral practitioner hncM many of the nniMCrt automatic
ally He hnev. hiv patient i heredity .u mcU hi Im eniiron
ment and tint Mai often helpful for initan e Mhen
the streii lyndromc hepan to deiclop One oliened
rJ/lTerrnJ mrmi'Cri of a hmilf temhnp in hrrai doxrj
tinder the «mc itten or under dilfercnt itrcaici in the
lame May
Ai mtdieme am! lutpcry and the allied »pecultict hectmc
more complicated and their lechnUpic more and mote a
mailer for expefti mIio Mere at the lame )oh all the lime
many helieic<! tint the pencral praclilioncr uai tfoomed to
the role of an mtclhpcnl iipopoit He t>chcied directly (he
oppOMte The piticnt could not he divided and If any
fpecnl aipect of him had to be inveitipated It mu the duty
of the penetal practitioner to ovence tint invcitipaiion to
the iiimoii limit of tili undefstandint and to enviite that
the spcciilly Mm applied to the patient in full InoMltdpc
of the patient i circtimtlancei The pcneral pracliiioner
muil not lend Ins pilicnl to lioipiial and fort el all ahoitl
him until he came hacl. npain
Rciponiihdity tn pencral practice Mai continuoui and
somclimci tool the practitioner a conuderable dm incc aM-ay
from pencral medicine Ocncral practice involved the Ircit
mcnl not so much of the pomlilc triviality which hid caoicd
anxiety in the home and pethipv in the ncij hhoiirliood ai
of the herd panic itself It wai for the pricliltotier to allay
that anxiety as well ns actually to dninosc and treat the
case
nlrlli and Death
At no time was this more marled linn on the two preai
occasions of birth and dcith AI a birth there Merc more
people in the house than the mother ind the child There
Mere the expectant father and Rnndpircnis ind their treat
ment could be ns prcil a trial to the icncril practitioner is
the hinUlint of the confincnicnl itself Derth ipain ssas
somethmt which Mas the concern of pencral practice there
wis not only the dyinp patient mIio mis usually the least
conscious of the concern he aroused hut his family and
friends The vviy m which the death ssas hmdlccl bv the
general practitioner might m Ac ill the dilTcrcnce In an
age which must regretfully be described as irrcluioiii there
often fell to the gcncril practitioner on such occasions
something of the function of the priest
In chronic cases it was often said that nothini could be
done But general prielicc consisted in doing something
to make life as bearable as possible for the palicnl and
to make him live as comfort ibly ns he could with bis dis
ability On the research side ihcrc were v irioiis mailers
which might engage the practitioners atlcnlion such is the
observation of seasonal epidemics not necessarily the serious
epidemics but the minor cases the transient vertigo nausea
and vomiung the epidemic myalgia the occurrence at cer
tain times of a series of cases of acute bickachc or pain
OB turning the head
ftimw
Mroicet rouiMAL
Dr Barber said in conclution that general practice was
still and iilways would be jim what the individual general
pritlilioncr made it It vas not a quciiion of defimiion
by any medical body bul it was the g cncml pncliUoncr s
own eonccplinn of service to tin palicnii exemplified by
the itindard of hn wurl and hn Milhngnen (o accept
reipofitihihly Ir »ai the whole care of his patient in the
numial environment and to the mmoit extent
I rperfi In Divlronment
Dr J 1) Sinpsr) ( tr anibndgel said that the general
rractitionT knew I ui little of clabotalc techniques in
diifiiosli and iteilm'-nl h' ncccpicil them and wed
them to ailvoc or treat the patient tn relation to his or
1 cr backtround and it uii of ilm environment that the
rencral practilloacr ifioutJ hive special knowledge
Or Simpson give inslaneei in which the qticilion of fit
ncii for alhleti~i tame N-fore ih' general practitioner
npcciatly in a iimvcriity Iomti On such occasions he
mint rely on his Inoivlrdic of the palienl the game itself
and flit oun immednte /udiimcnt
Another pruhtem wai fin and faints ” Just as one
SMattosv did not make a summer so one tramienl loss
of coi's^iiiitsness did not justify a diagnosis of epilepsy
In these days of the svorship of scicnlific invesligaiion
Ptaclitioncfs Mere often asked to have icm carried on!
An eleclroeneephalogram would la lh^c circumvlanecs in
easel out o' 10 only confuse the issue and so would the
aclininistration of phenobarbilone to stop any further fits "
uhtess the orginat attack tiad been seen by a rtallv relublc
Witness and there was no question at nil of the diagnosis
A quick reference to “fils" in a medical students text
book would soon convipce the palicm that he had epilepsy
With all 111 concomilani misery How mueh better and
more courjpeoiii to tell the palienl lhal ii svai a faint
and to nail without Rising driipi until the next atnefc
"luch niighi never occur Sometimes of course the dsKtot
"mild N* wrong and there might even be trageslv but he
mainl lined that the number of patients saved from the fear
sif a disease which they Ind not pot would amply justify
this action
Kfsearth fn Gentml Practice
Dr Simpson addcsl n word about research in general
practice The opporiiimlies for research were twofold
Tlicrc WIS first the longterm collection of cases of a
panicutir discise Wien p! inning a definite mveitigalipn
of this kind the pnctiiionct should seek itatinical adiice
at the outset and use a speci it forTi for hn notes so that
they miclit be of real s due Nothu v is more maddening
lb in to look up a past case and firj lint the notes were
mcompleic so tint the cue couM not be included in a series
Ills second opporiumiy for reseirch was in the recojni
iKm of climval syndromes ssficn these occurred in epidemics
Tsir esauiptc Ihc spcikcr hid recently had n group of cases
of gistro cntenlis with suih violent miestinal colic that
heavy sedation had been nccc's iry He bad Ind IQ such
ciscs within four sliys Dcscripiion of such outbreaks at
mcciinjs of the Section Mould he of the greatest saluc
In toncliision he summarized his views of the special
responsibilities of Ihc general praclilioncr as follows
(I) he should he csperl m the cnsironment of hiv patients
(21 III. should have the courage of hts consictions and not
be afriut of accepting responsibility sslicn this ssould sasc
hi\ paliems fear ind niixicty (3) he should bring to the
ness Scclion of Gcncril Pr ictiee notes of the pattern of
common diseases so tint general practitioners could learn
by discussion in the same w ly as their specialist colleagues
“Only n GP”
Dr r P Scott (Mnrylebone) declared that general pracU-
lionciN were the backbone of the medical profession There
had been a slightly derogatory feeling about people who
Were in general pricticc — they were only GPs — hut
Jan^ 6, 1951
repoiIts of societies
Bmisn
Medical Jourkal
35
this was unjustified There were certain attnbutes which
every practitioner who wanted to be successful must possess
The most important was personality the second a know
ledge of his work Perhaps the third should be luck and
the fourth a combination of a warm heart and warm hands
He quoted Lord Dawson of Penn as having said to him
The treatment of patients is 50% the treatment of the
relatives On the question of research in general practice
he mentioned the achievement of Sir James Mackenzie who
did all his research work in Birmingham as a general
practitioner
Dr C H Bjllington (Haileybury) spol e of the interest
of general practice at a public school it was the more
stimulating because it was concerned with health rather
than with illness Dr Rayner (London) said that general
practitioners very often did not p-iss on sufficient informa
tion when their patients went to the hospital or the specialist
Dr Lawrence Dulake (Reigaie) said that the work of a
general practitioner depended so much on the neighbour
hood in which he lived the kind of practice he followed
and his individual personality that generalization was diffi
cult Patients often expressed a desire to see a proper
doctor The general practitioner was a proper doctor
All the rest were incomplete doctors Doctors had some
times been divided into two categories — the tut tutters
and the pooh poohers He specially deprecated the tut
tutters for they somehow communicated their own real
anxiety to the patient At least half of the patients coming
to his surgery suffered from some psychiatric upset Some
times this was an overlay but very often it was the mam
trouble
The Bottle of Medicme
Dr E T Hughes (West Wales) said that when he looked
at Sir Luke Fildes s picture The Doctor (the original
was in the. Tate Gallery) it made him feel very humble
There was much that they the younger men could learn
from the old family practitioner He himself succeeded a
dear old country doctor of 83 and he learned a lesson a
very few days after entering the practice A woman came
in for a bottle of medicine and with some pride he dis
pensed it quickly and deftly from the bottles on the shelf
The woman looked at it with suspicion She evidently
thought he had left something out Later on he had an
opportunity of watching how his old principal did it He
fingered the bottles carefully choosing one and then another
with great deliberation and the pipe in his mouth added
a certain leisurely dignity to the proceedings Probably
the impression it made on the patient was more \aluablc
than the ingredients themselves General practice «aid
Dr Hughes was the practice of doctonng The specialist
went into medicine is an intellectual pursuit and thereby
lost some of the sense of vocation
Tellmg the Patient
Dr L W Batten (Hampstead) said that general practi
tioners were the only people in the profession who looked
after the whole person and he did not think this could be
done by teams One of their jobs was to try to explain to
the patient whit was the matter with him a thing which he
was not told in hospital A cause of the frequent dis
satisfaction with hospital treatment was that although the
patient received proper attention he often came out without
" ever learning the nature of his illness and accordingly felt
that he had been deprived of something People sometimes
spoke as if It wis easy to persuade patients to be well
Genera! practitioners knew how difficult it was It was as
big a «in to start an imaginary disease as it was to o\erlook
the beginnings of a serious one The general practitioner
had not only to introduce the specialist to his patient but
in a sense to protect the patient from the specialist Sad
would be the lot of the patient in the hands of the specialist
without the general practitioner in the background
Dr M C Andrews (\Vemble>) said that it was not quite
fair to suggest that the consultant treated the patient in the
zoo whereas the general practitioner treated him in the
field A great deal could be done by getting the consul
tant to come as often as possible to the houses of patients
and for that reason he tried to limit the number of con
sultants he called in and thus they got to know not merely
the patients but himself and his own personal attitude to
his patients Dr Andrews thought that broadcast features
such as the Radio Doctor and also articles by Nurse
So and So in women s journals could well be dispensed
with but that much good might be done by bnnging togethe-
groups of people who were suffenng from the same dis
ability as was already done m some cases with the deaf
or the partially blind
Dr E M DiMOCk (Broxbourne) said that general practi
tioners by the way they handled the family prevented a
great deal of ill health He considered that the psychiatrists
were making heavy weather with lots of incurables who
might have been picked out and dealt with if general practi
tioners had had better encouragement from the medical
schools Dr A Talbot Rogers (Bromley) spoke of the
general practitioner in committee work and m planning the
medical service locally and centrally Dr St G B Delisle
Gray (Walthamstow) said that one of the troubles with
general practice was that the youn^ men in hospital did
not know what general practice was The important thing
was that young men before they specialized should learn
something about what general practitioners did in the course
of their work All men before they went into a specialty
should spend 6 to 12 months in general practice
Dr Barber in replying on the discussion said that of
course he had not suggested that the general practitioner
should refrain from examining his patient but without the
case history the examination might be futile He agreed
with Dr Hughes about the value of the bottle of medicine
It should be borne in mind that the practitioner when he
came into a home in which there was sickness brought a
therapeutic influence or should do so but there was likely
to be a return of anxiety after he had left The bottle of
medicine served as an emblem of his continuing authority
The annual report of the Government Chemist (H M S O
1950 price Is) contains many matters of medical interest
The department acts as a kind of national public analyst and
has to solve such problems as how to detect horsemeat in
sausages or wax in sweets and to watch over the quality of
national flour and dried milk which it reports to be mam
taming a high level Indeed the milling of the flour has been
slightly improved since there is a drop in its fibre content
the Vitamin B, continues at just under 3;ig /g and 14 oz
chalk is added per sack But research is also earned out
During the Olympic Games 1948 diet analyses of the food
eaten by 28 competitors of eight nationalities showed that
the daily calorie intake of the athletes was on the whole
lower than that found at the last Olympiad in Berlin One
Mexican was taking only 2 100 calories while one British
competitor had over 4 600 A suggestion that old worked
out gravel pits should be filled up with dust sieved from
household jefuse was studied to see whether land could
thus be reclaimed but analysis showed the dust to be up to
53% organic mailer and expenment yielded a polluted water
Some of the investigations are more adventurous Ambergris
the calculus found in the gastro intestinal tract of sperm
whales which have been feeding on cuttlefish is being studied
on behalf of the Discovery Committee By the analysis
of fluorine in fossil bones it is possible to go some way
towards dating the skeletal remains of prehistoric man and
the department has been busy in this way on the Swanscombe
skull and the remains of Piltdown man An attempt to
decide whether potterv found on an ancient British home-
stead about 2(X)0 vears old was made from local clav was
inconclusive the x ray diffraction patterns of clays and pots
were studied and trace elements estimated m order to make
comparisons of the composition of both pottery and (ocal
clay
36 J\N 6, 1951
Correspondence
Appendicitis
Sm — I rcid the 'trttclc b> Sir Cecil nnd
Mr Peter Childs (December lO p I't-S7) utth much inicrcst
but with 'll! respect 1 feel 1 must comment on one or tvso
points first out of f iirness to m> htc chief Jimes Shcffcri
nnd secondly \% n result of m\ o\sn cxpcnencc
It IS correctly st ited ihil t!ic number <if dcillis from 'icute
ippcndtLiiis r'lpidly fell from 7 0^7 in lOlS to I O/p m J94|
lliis SS1S folloucd by n stsiionir) period for three ycin
In ^ further fill b'*! in uhich Is contmulnj, ind the
hlest i\ III iblc hpurc (Pt 7) shovss \ 401 deiihs they also
stitc thil the two penotU of irnprosemcnt were due lo the
iniroduilion of sulphommides 'ind perntjllin rcspe<iivcl>
If 50 why the three yeu mid \\^T period when there was no
lack of supplies of nniibioiics A more hlely explanation
IS tint csicuiicd children sscrc scattered over the country
commonly awn from parental supcrsiMon under th'‘ cxrc of
osensorled and often elderly prnctitiorers, rod svrth only
cott ipe hospjt il facilities in n any cases Sulphornmid'*'
and penicillin have doubtless helped but oihcr facto t arc
of impofiancc in this welcome reduction m mortahiy »\ I
base alrculs suppested in a recent article (Chr S I'>*0
19 IK2I
Parenls pfactltlon'‘rs and xurpeoas all played a part W
ncbicsinp ihis wcIcutc Imptosemeni*— parmti I'e au e they now
but rarely pour caoor od into unwd’np itomachs praciiun ief>
on ac«.ouni of earlier dinpnoos and a preaief ^•‘^r rf mpency
and suffcons tv-cause the danper of tie ruVofihimdi n^dosl
of imnrdiaic operation on nil cases h inaeasinph appreciaied
and cxpei.innt trcaiment i npldl) csmsulcrcd in cases who ote
too liie for the early operation nnd too early for itic late on**
Sulphonamidca and penicillin nl o deacne credit In felpmp to
control infection
Il is silted If the diafnosis is nppcndiciiis and if it is
cicnriy not chronic operation is urpent lliere is no place
for expect ml treatment Also we arc reminded Ouit 5lncc
I adsoented expect int treatment in an iriiclc in 1*^17 the
follow inj, hasc been adiled to the siirpeon < arnnmenlanum
sulphonaniidcs penicillin mtrasenous drip thcripy and
gastric suction It is obsious that these new asfddions arc
just as s iluablc in eases treated expectantly is for those
opented on it any time The three cases referred to in the
article m which the expectant treatment of appendix
mass filled were certainly unfortunate but over t hrge
senes of eases at least 90% were found to subside with the
recent additions lo the surpeon s nmiamcntariiim
As ulmiticd in the irticlc nprcndiccctomy is noss always
possible if an immcdntc operation is performed It is
stated Where m abscess w*as found surroundinp the appen
dix the appendix was removed whenever possible also in
the ease of an appendix abscess ilic appendix was not
removed unless it was rcidily accessible llicsc piticnts
having survived the exploratory opcrition presumably
submitted to a second operation for appcndtccclomy
There arc many otlicr points one would like to raise but
spice forbids so I conclude with and endorse the slitcmcnt
of J imcs Sherren who after twenty ycirs experience at the
I ondon Hospjtil vvroic in one of his hs! papers (/JrU^s/t
Medical Journal 1925 I 727) The only ch'inpc I have
made has been to greater conservation and more patience in
dealing with ciscs of appendix abscess — I im etc
London VV I R J McNl ILl I OVI
Bmtwt
Admittedly (he most important adverse ficior in morbidity
and mortality m acute appendicitis is late diagnosis The
next most impoftirii uticf e factor is the indiscriminate
employment of the mmcic split mcision This incision his
been liuphi in our mcUicul Hhooh and practised all over the
country since operjiion fust became rccoynucd as the correct
tfcaimcnt for acute appendicitis >ct it is a bad incision
with little lo recommend it
11 c eomnionesi caui'* of deaili In aaifc appendicitis is inicsthsl
olntiucilon Tins Is due to rvrpnniiis cider localir d or
icnciahred and now bappdy airenaldc to consnleraV'^ conuol
hr d frnod crapy pastrre su-iion and miravrnoas dnp ibcrapy
llu the icndcacy in intn ma! olntrucuon n ar-ravated b> iraum
to tv-dcmsiDut tiinres In th'* Pco-caccal anpJe at tie urn'* of
o»w-faiion esp^tsdy |o the Uu iaJi of ll " I'-um In il presence
of flcti ely ^wol'en and cvrderrjtous (issues ii is often verv ill'll
cull (o deliver lie appendix from tic retro cac».al or p-'lvic
po\ ions (It ^ commonni) ihrnu*h ih'' Imnled esposme of the
iimu‘c sp‘it metuna and ev^n if Pc laciuon ii entarp'-d bv ibe
Uiilfffod ‘tun on frir ’e-cuiiihr rnethixl th** de-asioa to do
so t\ ft at*c 0 tt> fthrr cons derabtc tnurra has oeeuffcd TV
ir«rc slidul tl e surp^u i iV leas is th" trauma but no suffcon of
esp^n ft can lool 1 a V. over lit career and rot rreo'-ea rsny
diP» u!t t luc-lea to d'‘livef an appendix 11 rojfh a r'uscl‘*-splu
h ii on Mo CO rr It - o'^raiion fo a-n.ie appea is piv
ei tret ll e (faif’i''2 of^iaiioa for 1 ou e surf^^jns ard rcpisuars
all oscf th- coiiftlry ami lo loop at (ley are taught to rralc this
It cn dev loo Hfd I le a"d Iram bv Nrirr ttrertrrce ard
1*^' mo (ality rale fror^ am c apperdnui wHl rot improve
It U rot su'' "srri lo maVe a diapnosii of am c appendi iiii
Tie surpeon s* ou d assess in bn m f'd as far as posub'e the
position of d e nppeoiht and (he probahl*' cxicni of oedema end
indura ion of surri uri'in- tissv.^ the I'^j^ih of his o y hemp ih*"
noi! irpt-*rt*»rf fa to to Var In m nd TV r-isin shnu'd be
p^an»'td aecofdmtl) In of cases It will be fou"!! ilat iV
rifht psrarvshan Incrtion es'endi'^g from tV l*vel of the
umbilicus to ore inch a'xwc the pul s wil pivc xn casv and
xdequsie cxposiue threuch whuh lie caecum nnd tenmmal deum
cxn V t^ntly c»evaied and drawn towards iV r'ltllme with 8
minimum of trauma triJ tl e aptvcndix remostd ro mxt cr in what
poiiuon It msy be Centlcness In tie bandlmp of acutelv
iiiflanKd us ues (s iV kev lev ihe fimler reduction in nornhtv
in nevie appendi lUv It is also th** key to ih'^ redotinn of
wound infeciion winch is more ctvmmon in muscle sp’it sncssioos
whJ h irijidre irtt»*Xion som**imn fo ctfU than in patnmetlisn
Incltlont, which require none If a locah ed appendix aVeexs in
(he right ihac fossj reruircx drainap^ a muscle sphi Jncision over
It IS ibe besi approach Stmibrh in a late esse In which (he
appendix is pnbed (o he in (h- hiph rctrocnecal or px^acf^hc
posmons n Rutlicflord Monson incis on c** Inlth is the best
opprovch In nil other insMneex the pnran'xltan In^sion ts the
b^t pirtiaihrl) so for the pcUic appendix in wlu h coriect
dhpnosis is so siften delayev!
Tlic musJe sphi Incision as a routine mus po It is a relic of
the pxs of (lie bxd old dnys of indifferent anxexthcsia
Hie rccommcnt^tion of the muxcic split incision for ncutc
nppemhcitis iv dcbatiWc Its recommcndnlion for chronic
nppcndicitix is bid surpicnl tenchmp The luthors ndmit
in Tnblc IV tint m 12 out of 39 cases so (rcited the
'ippcndiccx were normxl on pxtholopiCTl cximination WTiv
then the muscle split incision md whit wis wrong with
these 12 pilicnls *> In all rises of co called chronic nppcndi
citis the parnmcdiin incision should be nnde so thii the
pelvic organs nnd tcrmmil ileum md mesentery nn be
examined nnd the pill bhddcr and kidncv pxlpited Many
patients who b ivc subsequent opcnlions for pain in the richt
side of the abdomen nhcady bear the tell tale small scar m
the right line fossa of which they and their surgeons were
once so proud but with which they nrc now so disippoinicd
—I nm etc
Amcrvham m.ck, UonrRT StRXNO
CORULSPONDCNCn
Sm —Sir Cecil Wikeley and Mr P Childs arc to be con
gratuhted on their 217 eases of appendicitis without a death
(December 16 p 1347) A benign gremlin must be looking
after their eases for in combining a recommendation of the
muscle spill incision with a condemnation of expectant treat
ment in late cases they arc surely doing a disservice to
surgery
Sm— Sir Cecil W^kcley and Mr Peter Childs (December
If* p 1347) hue igiin focused attention on thiv important
subicct T do not think it is sufficiently realized how
ignonni the general T’ubhc is of the svmploms of
ippcndicitis and how prev dent is the pernicious custom of
liking a purgalivt pirticularlv castor oil wJicn abdominal
pain conies on rour recent cases have shown me how even
Jan 6, 1951
CORRESPONDENCE
Bxmsit
Mcdicai. JOimUL
37
among intelligent v.ell educated people this dangerous trust
m the castor oil bottle persists sometimes 'A'lth disastrous
results
Case 1 — A woman 75 years of age had a central abdominal
pain accompanied by vomiting The pain moved to the nght iliac
fossa next day Her daughter a school teacher gave her a large
dose of castor oil on the following dav and the symptoms
became much more severe her doctor hov,ever \\as not called
m till the day after A few hours later I removed her gangrenous
perforated retrocaecal appendix a faecohih was l>ing near by m
the poorly walled-off abscess cavity in the right iliac fossa and
peritonitis was spreading Drainage of the abdomen was neces
sary Severe paralytic ileus ensued and her condition was pre
carious m the extreme for a fortnight Fortunately with chemo
therapy " gastric suction a blood tran’vfusion and intravenous
fluids she rallied and eventually made an excellent recovery
Case 2 — A man aged 48 had crampy pains in the
upper abdomen following a hearty dinner Next day the pain had
shifted to the right side He took a large dose of castor oil
and though his bowels moved the pain grew steadily worse He
called in his doctor on the afternoon of the day following
By this time he was feeling pretty ill and was extremely tender
in the nght iliac fossa At operation that evening I removed a
perforated retrocaecal appendix from a well walled off abscess m
the nght iliac fossa and drained the abdomen with a stnp of
corrugated rubber down to the appendix sue He made an
uninterrupted recovery after a full course of pentallm and
sulphonamides
Case 3 — A woman aged 72 and extremely obese had central
abdominal pain and vomiting Next day she look a large dose
of castor oil The pain became worse and she was admitted to
hospital late that evening Her urine was loaded with pus cells
and she was observed for some hours as a possible case of right
pyehtis Tenderness and resistance increased m the nght iliac
fossa and 1 operated on her on the following day At operation
a gangrenous perforated retrocaecal appendix was removed and
the abdomen and abdominal wall drained She made an
uninterrupted recovery
Case 4 — A man aged 69 had central abdominal pam at
3am following a dinner party He vomited and in the mom
ing he took a large dose of castor oil The pain moved to the
nght iliac fossa and became severe His doctor was called in
that evening at 7 p m Two hours later I removed an appendix
lying in the subcaecal position 6 m (15 cm) long black the whole
way with a faecohih blocking it at the base and the lumen full
of dark fluid Local penioneal reaction was slight Fortunately
the removal of the appendix was easy and recovery was
uneventful
These cases illustrate what has been noted frequently
before that castor oil taken for abdominal pam which
happens to be the start of an acute obstructive appendicitis
acts in the abdomen like a match applied to a powder maga
zine It stimulates a vigorous peristalsis and so accelerates
the progress of necrosis of the appendix wall at the site of
the obstruction (usually a faecohih) with consequent per
foration and discharge of the highly infected contents into a
peritoneal cavity which sometimes has not iiad time to
prepare effective barriers
As no one can tell if colicky central abdominal pain is
not the commencement of an attack of acute appendicitis the
administration of a purgative particularly castor oil in such
a complaint is obMOUsly an extremely nsky and unwise
procedure There would seem to be considerable scope
here therefore for members of the medical profession to
enlighten ind educate their patients and so help to lessen
the dangers of this disease and also give the surgeon a
chance to remove the appendix before it has perforated
— I am etc
Edinbursh J A RosS
Economics and Medicme
Sir — T n the man> discussions that preceded the introduc
tion of the National Health Service speakers rarely talked
finance and when they did were not infrequenil> rebuked
that we were righilj more deeply concerned with ethics and
high principles Some of us fell that m the course of time
economics would enter the picture Hopes were pitched
high on the pro'jpect of bicger and better hospitals fine
equipment great oppommiiics and no financial restnctions
All this might have been possible m an expanding and
flourishing national econom> However for man> reasons,
including inflation and the cost of defensive rearmament the
funds have not been available Boards of governors have
been placed on a restrictive budget new buildings and
equipment have been deferred and expensive preparations
such as penicillin and hormones curtailed to essential needs
As to general practitioners financial terms of service have
produced hardships and serious negotiations are afoot If
inflation proceeds these hardships will increase Even a
socialist medical association has sent a telegram to the
Minister We want increased salaries and belter working
conditions As to consultants those who have looked
entirely or largely to a fixed salary by the week or by session
do not find financial conditions easy Those who still look
largely to private practice may have noted that Harley
Street as always tends to reflect general economic condi
tions and that higher fees proportional to inflation are not
popular Consultant trainees arc- finding few staff vacancies
as the hospital service has not been able to expand as was
initially hoped
What does the future hold Current articles in economic
and financial journals take the view that adequate increased
taxation to meet the Government s financial burden is not
feasible and is apt to defeat its own purpose They turn to
xthe question of cutting Government expenditure (although
It IS more realistically a problem of stopping it automatically
rising) and they end How in these circumstances can the
Welfare State survive ? Some point more directly to the
National Health Service No one knows the future but
all the trends point to the danger of a lower economic status
for the doctor unless some reorientation is possible I would
suggest the need for a permanent economic advisory com
mittee including economists to study these problems
My own reflections are as follows financial conditions for
hospital residents and registrars were determined by the
existence of a large body of ex Service men They should
now revert after an appropriate interval of notice, to those
of the order believed adequate m pre war days Marriage
for the young doctor could reasonably be deferred until the
age of 30 unless special circumstances determine otherwise
Moderately senior consultants might consider whether they
“ could give up some of their hospital sessions to make room
for a proportion of the trainee consultants This might
involve some temporary hardship but a return to a more
balanced proportion of private work would in the long
period prove generally beneficial and prudent
It may be that sufficient private work would not come to
all and some reduction of fees instead of augmentation
might call temporarily for harder work and less reward In
my view under these circumstances there will always be a
number of patients who are willing to pay for such pnvale
consultations and the argument that there are not enough
consultants for the national health scheme no longer holds
This might also be the trend of events in general practice
Interest in insurance and provident schemes for meeting ill
ness should be revived and encouraged The pendulum has
swung too far and too fast as the late Lord Dawson feared
It might and its correction will relieve the burden of (he
Government and the hospitals and leave the profession in
a more prudent position to maintain their proper economic
and social status and to meet the adversities of economies
as well as relentless economics — I am etc
London. VVl S LEONARD SiMPSOS
A Co-ordinated Policy
Sir— The outcry which has been aroused by the reduction
of the registrar establishment seems to me to show up the
inconsistencies of our own attitude to medicine to-day and
to the National Health Service On the one hand we cry out
IhaT over specialization is diminishing the scope and lower
ing the status of the general practitioner and on the other
that more and more' specialists are required We say that
the general practitioner should have fewer patients and a
higher capitation rate which means more money as also-
docs increasing the number of specialists Is it really likely
38 Jav 6. 1951
CORRESPOND! NCE
n*mni
Mmicii Jochnal
(Int the coiinlr> nn illord nn> hrper Mim fur tlic Hcillh
Sen ICC 1 Js It not more lit.clj tint in> incrcuc of the
illotmcnt for the nho\e purposes would tme to come b>
rcndjiistment of the present rite of rcmimention ? Oupht
we not to In\c i co ordimied pohej with priorities?
We deplore the pip between jcncril pncticc on the one
hind ind hospitil ind spcciihst pnctice on the other hut
in) ittcnipt It or siipRcstion for hridpinp the pp is
cflcctiiel) opposed not b> the idministritise side of the
Sen ICC hut b> one side or other of the profession
It IS Slid too tint the hospitils cinnot function without
their present niimhcr of repistrirs Hut do they function
an) more cfHcicntl) thin the) used to do with smaller
numbers 7 In spite of n mcdic-il ind cicricil stiff preater
thin c\cr before it would ippeir to he usinl for at leist i
sscch to clipse iftcr the disthirpe of i patient from hospital
before i letter is sent to his or her doctor Inscstipitlons
ire neccss iriU more seirchinp thin the) used to be but
much time and monc) arc Iwinp wasted b) blunderbuss
invcstipitions and b\ patients proccedinp from one sp'cnlivt
to mother (Is it neccssir) for i phyliciin to refer in
isthmitic to in illerj ist for sbin tests i) 1 here seems to I e
1 tcndencs for consullints In hold ippomtmenls at is nun)
hospitals IS possible with the nilunl result tint the) ire
unable idequitcl) to supcnite the worL at ins of them
How nre loo it ssould ippeir to be in some clinics for an
out piticnl to pet beyond the rcpistrir and yet it is often for
the consultants experience ind opinion that the patient is
sent by the pencril priclitioner Is not the term sp-cnlisi
becominp more ipproprnle than that of consullinl — I
im etc
K C
n C G nnd Sarcoidosis
Sir — I was tnicresicd in Or I F Crawley s report
(December 16 p 1361) of three cases of eolti'ioi nodostm
IS a mimfeslalion of Iloecl. s sircoidosis
Tlie recent isiilibility of (ICG (ues the physician iddi
tional help in provinp a dnpnosis of sarcoidosis Sulrberper
ind his co workers (/ until Ptrm 1949 (3 *••'>) base
shown the differences in local response to 11 CG in cases
of conpcnitil and acquired luberculin anerpy Secondly
nCG Mccinilion will not consert the posiine anerpy of
sarcoidosis to normal tuberculin sensitisily (normerpy) — I
am etc
rUcisarc Middlesex C D Csisss
rrjllicmn Nodosum
Sir — Dr r r Crawley s inicrcstinf paper (December 16
p 1361) once more ruses the question of the acliolopy
of this disease Perhaps my cspcriencc mas throw some
light on this Since iqit 1 hue been treating erythema
nodosum with silaniin k with the result ihil the condition
has clcircd up in from one to three days flic dose of the
vitamin appears to base little influence 10 mg of the
synthetic vitimin twice daily ippcars to be as cITcctivc ns
larger doses Those cases seen in the first few days cleared
up within 24 hours Those who had been ill for weeks or
months took up to three days Unfortun itely I have only
hid eleven of these cases in five ycirs md up to a few
months qo was not in a position to obtain accurate
prothrombin estimations — 1 am etc
Ilclfasl T A Kl AN
Waiting lists for Tonsillectomy
Sm It IS a matter of concern how ifie many children
waiting to have their tonsils and adenoids removed arc to be
treated in view of the 1 ick of hospital beds in which to
put them In many localities the w iiting list runs into
thousands and children have been willing so many years that
vve may expect to see their offspring appe iring in the ENT
climes soon Some I have seen grow out of their disibility
and doubtless many children could be better trcited by con
valescent treatment m the country with proper diet and
environment but this seems to be unobtainable New
Zealand I read has arranged these facilities and I think if
vve had them we could save i lot of hospitaliralion, with its
preater cost I would life to put in a pica for a consideration
and development of this type of tre itment for patients bt/ore
they become in patients — I am etc
txipiJoa vv I C llAvinik Thomas
Introducer In Wood Tmnsfiivlon
Sir — Since we have used polythene tubing for blood tranv
fu ion or other intravenous work it has been found that the
introduction of i needle into n vein and threading polythene
tubinj thiou)h it iv a ihoroiighly clumsy pro-edurc 1 have
therefore designed an introducer which is illustrated here
The Itindle o^ th* introducer is about the sire of a 6 ml
hypodermic vvrinpe md has the same feclinp when handled
It gives complete control of the needle "nic male end of
the inirodi'icr is a Kccord sire to fit the ordinary
M RC donor needle Ihrouph wliitli eitl cr sire 1 O'" Z pol)
thenc tubing can be inserted The handle of the introducer
IS yrooved (which is not seen in the photograph) and the
tubing hes in it When the handle is gripped the tubing is
therefore ptevcntesl from slipping backwards and forwards
in th- reedle Wlrn the reedle has teen inserted into the
vein the introducer is disconnevted and the polvthcnc tubing
introdiivcd as far is nescssaty thfoi gh tl e needle The
needle iv then removed leivinp tli' polvthcnc tubing m the
vein md is taken off the other cm! o' the tid mg so that the
tubing can then Ic coniievtcd to the gisini apparatus Tins
polythene introdircr was made for me by \Ilcn and
llanburys and lias 1 cen tlioroiighly testcsl and found to be
extremely sitisfaclory — I am etc
\trc E ilLsxuL
CiS gfsirt R -aij TiiO lusisn OmKr
Death from I xsanRuino-transfiiMon
Sir — I torn a study of the literature of cxsangtimo
transfusion in adults and from corrcsponilcncc with us chief
esponent Dr \1 llcssis it would appear that the manccusre
IV almost entirely free from risk We consider tlicrefcre
tint i faliluy irising from this operation should be reported
In n ssmiian of 41 siilleiing from neiile monocytic leukaemia an
cxsangiiino Irinsfiision calculalcd to replace 9sn( of ihe paiicnt s
blood was planned Caicful physical mil radiological cxanilnaiion
prior to Ihe ii|ierauon failed lo reveal any conctiricni disease
Thirty five pints (19 f hires) of blood were evthamed at a single
session over iht course of sis hours the paiicnt liemg licparimzcd
and the blood given into boili nrms while wululrawal was clfevicd
by n ssidc bore poly diene cannula m the left femoral sein Prior
to the opcraiinn the paiicnt had rcceiscd sis pints (3 4 lures) of
packed cells which had raised her haemoglobin lo 13 p 0
During the course of the transfusion Ihe patient des eloped
sympioms of tcinny which were pronipily relicssd by iniravenoiis
injections of calcium gluconate These svniploms recurred on
three occasions and gacli lime required n Inij cr dose of calcium
ghiconaic mirascnoiislj to effect relief At the end of the
cxsanpiimo Irnnsriision symptoms of Iclany njain became
mamfest nnd nllhoiigli they slowly suhsuled iificr administering
n total of 120 ml 10"o cniciiini gluconate the patient died
Post mortem cxaminalion confirmed the diagnosis of nctile
monocytic Iciikncmin hut also rcscilcd tubcrciiloiis infilirnlion nt
the npex of the right lung with scry early miliary iiibcrclcs in the
kidneys nnd spleen No oilier nolnblc changes were found
Jan 6, 1951
►CORRESPONDENCE
Bwmn
Medicxl Journal
39
We believe lhat this patient died a biochemical death due
to the transfusion and lhat tuberculosis played little or no part
in the outcome The biochemical changes resulting from perfu
sions of large quantities of citrated blood ha\e not been
adequately worked out Certainly the amount of calcium
required may^ be \ery much greater than the literature would
suggest and until more accurate knowledge is available we feel
that a warning should be given of the possible dangers of
exsangumo transfusion in adults
We are indebted to Drs A H T Robb Smith H B M
Lewis and V T Pearce for their willing co operation
— We are etc P D Bedford
Oxford E G Lajtha
Salicylates in Post tonsUlcctomy Analgesia
Sir — In view of the fact that salicylic compounds reduce
the blood prothrombin level S L Fox and G B West
{Ann Otol etc St Louis 1948 57 1032) stale that the use
of acetylsalicylic acid is a major factor in secondary tonsillar
bleeding following tonsillectomy Furthermore the haemor
rhagic complications following the administration of sah
cylates may involve the escape of hypoprothrombinacmic
blood through capillary walls damaged by C hypovitamin
osis since salicylic compounds combine with and hasten the
excretion of vitamin C
Earlier this year I had my tonsils dissected and the resulting
severe pam and dvseorofort were rapidly dispelled by sucking
tablets containing acetylsalicylic aad mcnaphthone and
ascorbic acid ( ekammon ) which were recommended by the
ENT speaalist and no haemorrhagic complications developed
S Shapiro (7 Amer med Ass 1944 125 546) estimated that
1 mg mcnaphthone will counteract the prothrombin reduang
action of 1 mg acetylsalicylic acid and therefore these tablets can
be employed even m massive doses if required without the nsk
of induang hypoihrombinaemia and C hypoviiaminosis
I am relating my personal experiences with the sole inten
tion that others may be able to benefit from the analgesia
afforded by salicylic compounds and at the same time be
free from secondary haemorrhagic complications — 1 am etc
Haslloedeo Laocs H LeaHY
Tuberculosis and (he Health Service
Sm — ^Professor F R G Heaf indicates (December 16
p 1353) an approach to the problem of tuberculosis of great
value but since his methods require extra clinics extra
medical staff lay staff and ambulances they will find little
application at this present time However I think there is
a solution which is not only more economical but one which
will improve the whole standard of medical care beyond the
local problem of tuberculosis It is for the general practi
tioner to practise more medicine
The specialists in all branches looking at the small field of
their own specialty continue to press for more buildings
more clerks more equipment and a great deal more money
as hospital finances show And still they proclaim that
the general practitioner is the backbone of the profession
The general practitioner alone can integrate this health
sen ice which the clinical specialties the local health
authoritv the county health auihonty and all the other
highv\nys and byways of medicine arc disrupting through
Iheir specialism
The home treatment of tuberculosis indeed the home treat
ment of any disease is the job of the general practitioner
and the district nurse the two most economical units of the
Health Service My principal and I have already three cases
under ircalmcnt with porn aminosalicv lie acid and dihydro-
strcptomycin m consultation with the chest clinic One as
Profes'ior Heaf points out, has probably avoided sanatorium
treatment completelv and has had her disease cut short by
months With more time the general practitioner could do
far more artificial pneumothorax {A P ) refills for example
Now this could be applied to manv other aspects of medicine
All antenatal work should be done bv the general practi
tioncr and the abnormal case sent for consultation with the
consultant obslclnaan all child health work is in the general
practitioner s province and the difficult case can be referred
to the paediatnc consultant similarly with vancosc veins
asthma the rheumatic diseases venereal diseases etc There
IS no need for a separate doctor separate building hordes
of nurses typists and clerks This could lead to general
practitioners fully occupied in medicine and true consultants
rather than to the half world of small time specialists
In this instance of tuberculosis the chest physician should
be a consultant preferably of all diseases of the respiratory
tract with hospital beds under his care He secs the patient
advises on treatment (which the general practitioner carries
out at home) and admits the patient for short periods for
special treatment induction of A P phrenic crush etc No
need for ambulances — the general practitioner already has
them available no need for the staff of the chest clinic
to pay frequent visits — the general practitioner does that
loo Health visitor^ I am very sceptical about A general
practitioner with time to spare can give much better informed
advice in this highly technical phase of medicine
My solutions then are
1 A much reduced maximum list carrying a similar income to
the present This of course will mean more general practitioners
2 A reduction m the public health and special clinic services
These are responsible for much duplication we can ill afford
3 A discouragement of some of the nonsense in general
practice A scheme similar to the Australian where a list of about
170 urgent and effective drugs arc presenbed free and the rest are
paid for
4 This IS not essential but just a personal view a salaned
service Away with the cannibalism I think this would make
general practice much happier and would help one to treat
patients as one thinks they should be treated and not with an
eye to gaming or losmg heads.
— am etc
EontyOddd F M VaSEY
Sir — All members of the B M A must welcome the
publication of the Tuberculosis and Diseases of the Chest
Committees report (December 16 p 1382) It is a good
report but it does not go far enough in my opinion on the
side of prevention although Professor F R G Heafs xnd
Dr G F B Pages articles (December 16 pp 1353 and 1380)
help to fill the gap
The scheme under the NHS is uncoordinated and
unbalanced it is not that there is too much treatment
there IS loo little prevention The link between the two is
all but severed It is the duly of the Ministry of Health to
produce a co-ordinated scheme this it is not doing As I
stated at the B M A deferred Annual Meeting the attempt
IS being made to fight tuberculosis on the cheap and while
this IS so little progress can be made Payments urgently
needed have to be fought for in regional boards and manage
ment committees against all other interests from tonsils and
adenoids to geriatrics and in the final allocation between
treatment and prevention the claims of the latter may easily
be overlooked If a special tax of 10% or so were placed on
the sale of television sets a sheer luxury and definitely alio
cated to tuberculosis services it would go far towards
providing the needed funds
The preventive or epidemiological aspect should be given
the first consideration it pays double dividends If small
pox or diphthena had been regarded in the fatalistic way
that tuberculosis is wc should never have vanquished them
and mutatis mutandis we shall only cut the incidence of
tuberculosis bv one tenth if we attack it cpidcmiologically
by locating the source and preventinc the snread of
infection and by increasing specific resistance Every new
case has contacts who should at least be tested radiologically
and by tuberculin and if negative offered BCG A child
with a primary infection is often such a case
It IS true that we do not know the exact v’alue or duration
of the increased resistance conferred by B C G inoculation
but is that a reason for denying to contacts the protection
such as It IS that such inoculation indubitably affords The
fatality rate of tuberculosis in the first year of life is very
high 36% according to Wallgren and falls rapidly till
pubeny when there is again a sharp nse It has been showm
40 Jan 6, 1951
CORRLSPONDCNCB-
P»rmn
MftncAi latrtmu
in Dcnnnrk pirticiihrl> Copcnhitcn lint h> \ iccimlion of
infini coniici^ with BCG tiibcfcnlotu meninpin m infints
one of the pnnciinl cniscs of infintilc dciths cm be
MrtinlU siimpcd otit A'l Professor Ci mford once iml to
me of t, islro cnicritts 1 lie children die ind nol oil) t \ic\
It IS not onK the -100 \vccl.I> dc iilts— ihoit^ h Ihc Home
Oflicc uould not pit ilscll on the HilV. tf the polite hid
reduced the sveeklv niimhcr of niurd n from ‘00 to wy V)0
—there IS iho ihc intnien<e Ion of licdlh »nd of worlinj
hours involved leivmj hunimiv nidc prevention of
tuhcrcnlosis on in uleqinie venlc would he well worth whde
The proLcss of coni at liuntinj nnd inoculition tv lime
consuminp and requires enthuM ivni It \\ iu»t l'*int ide
qiMiclv done md cmnoi he done wilfi cvivtinp viiHs rncdKif
md Ollier these should he trehted to rcith the Oinivh
viindird Sir Kohcri I’hihp iv lie P »t c f'ointx out nitphi
thu tuhcrvuloMs w is prevent ihtc ind (hit the dopcnvitv vs iv
the centre of uu mteinted vwicrn of tre dment and ptcvcn
tion The present N H S vehen e is quite imdcquife on the
prcvcnitvc side With in idcqinlc preventive v>stem fevser
hci^s would h'* needed Is it nierelv in uhr prcjuditc thit
prevents us from uvinj BCG ideqtnlclv **
Ihc resolution of iIk It M A Anninl Kepresent itive
Mcctinp hst 'September condemnitij tlie cvislirp irriUfc
ments for luhcrcidosis w is pissed umnimouslv \| the
summer scientific mectme Professor He if pathips ot r Imh
cst luthoniv stited tint we must press fo m incrdinp
Act tint would cnihlc *i ♦'‘rvice to tc developed thd
could reduce the morbidity md mnrtihlv if this diseisc lo
m insqndicvnt figure Unid this is done we shdl pro~ccd
in 1 w isteful distonlcnied md di'ordcrlv n inner w»thnt
hope of m> red progress As Itie Scottish rommtilcc s
report Slid this crisis must be met in itic spirit of n cfimde
NVIut cm we do to rouse the Sfinistf> out of its compliccncy
lo tickle this mtiom! scnndil — I mi etc
Heswall Clie^*iirc C* O STAltMUISSS
Ilcirt Cases in Macs Undiocnpti)
Sir — H r Peter O 1 ct-nl ** '^rhclc iDcccrnher 16 p P64)
niscs points of considcnhle interest to rn-duil directors of
miss ndiocnph) units One of the most surprtsim ihmts
in re idinp I ir^c senes of mini iturc lilms is the cstnordin ir>
viriilion m the sire shipc md position of the t irdnc
silhouette most of these cases ire rcpirdcd is within nortinl
limits but numerous csmiplcs of considcnhle cnlirrcmcni
md ibnorimhiy of the cirdiic outline ire encountered
fn the pisf ciscs rcjirded is grossly ihnorrnd were
rcrdlcd md cximincd by the mcdicil director who sub
muted 1 report to the piticnt s doctor !l h is been felt how
ever thu this procedure w,is inulcquilc md recently v\c
hive csl ihhshcd i liiison wuh the c irdtov isi.ul ir unit in
the Ncwcistk Generd llospitil whtre l!lc^c eases cm be
ulcqintely invLstipUcd In ill ciscs i report is sent from
tlic tirdiov isLulir clinic to the puicnls doctor with t copy
to the medic il director of the miss riduqnphy unit In
CISCS of dextrocirdii where tlic ihnornnluy v\ is nol
known i kticr is sent to the volunteer in order to show it
his not been overlooked — I im etc
Newcastle up<>n Tyne 11 OlCKINsOV
Altlcclisis mul Ilronclucclnsis
Sin — I was interested to learn tint Or B Mann
(December 9 p 1331) had found in eases of rever
siblc bronchiect ISIS ihu the ininpleuril pre sure w is nol
appreciably lowered contrary to wlut would hive been
expected from \ perns \1 of I mcler md Dividsons (I93M
paper I ilso observed this pnz/lmp feature not only in
cases of reversible bronchiect isis but in pcrmincnt
ateleciitic bronclucci isis is well 1 hope shortly lo publish
an account of work on this subject but briefly I cinic to the
following conclusions
The essence of Lander and Davidson s important article was
that when pulmonary collapse due to bronchiolar occlusion
occurs there is a loss of spice in the affected hcmiihorax and
to compensate for this there is compensatory emphysema and a
ct»ni|KMiilory dilatation of the bronchi in the collap cd poriloa
of Uinp Intiaplcuial pfcauircs are rcadinpi of ih'* jas pres urc>
in » small afti(ii.nl pncumotlorav nnl five a m'‘asurc of the
meioj clutic icnvion of the luni It occurred to m** tl at if
folKwsjii" ctUlip e of a jvirtion of i! c lun^ the rcvuhinp increase
in fhatic tcnvion vsere hr>cl> locafued to the nflcvted part tie
coninired hfouthi mirhi t*-* dilated without tie intrnpkural
provurc v%hch rt «• uiica tic mi>4 n tcn'ion of il • lunp Ivinr
ii**ccatarily marked!) lowi rd ni 1 a^dcr and David on tvli^vcd i*
wav 1 liter read the c' cHcnt flfti k bv Andfuv (1957) in which
he stated that fol’oAinp p dmnnary collipi'* tic increwed lung
lire c* arc in fa t (ariciv jo a* /-nJ to ihc jflcvicd aro ll/ac
fo c U ou'*' I iln not I'chrvc ihai a low iniraplrufa) prc’ ure Las'"
art>tfdtu to do with d c prodi wito \ of bf( In «. atta or i r cn a
ci-ir» attiimpanim'ail of a ckitati 1 rtnit! tcc'aua I see ro
rca oi in 4hnd I the ca cn lal fca urea of Lnader and Da idma^
work
Nftifiti d pnciMvotl Of It Vs is employed on an ctp'^rimenial
I IMS an 1 not ■udcly ilv iherapeiUi cflecl Ilie aflecicd
bronchi were rot topMricfcd is Or Marn feared Th** lunc
V y\ relived until llte nhhre of the dilitcl bfon(.hi had
returned apptosu i iiclv to normt! is sIioati by broncho
pr iphy lilts V as ilu uj-hl lo be u'equ Uc to allow c '“ipc of
scw ctum othcrwis'' one woild lave to suppose tkai the
nofc mitket! the 1 roiwhicvt I'la in i collapsed lobe the
letter the prtnpccts of re cap muon
I hive to intc"Mon of p*Tcrali/irp from Ih- reaiiUs my
acn'*a of j'^rti sms esv-s bit 1 wvs «no*t ntcrest-d to find
till! D 1 1 inVhn (D- ciT 1 er 9 19^0 p 135 f) Jus noted a
Mtfiilar low It t kt ce of residual respirainry trouble 1
entirely aprcc wUh him that it is i asatisfactory to bhme
pertunis fo- bfOf chicvtisis on th* strcnpih of a hoio v tiken
often Vfirt after l!i- I'eyinniPj of svmptorrs at the same
litn'* I hive cpLOurtcred a fev cis's out of stores in vshich
the com evton is to > clear cut to le serioi 'W doubled
! vpericntc of brc^rcluccl isis csanvmces me that D T r inVIn
IS coned svhen he sava that the prognosis of brorchiectasiv
in childhood is nn eh letter than is tommonly stated
Nevertheless | stdl think that there arc unihtcrat cases in
vshich the dlctlion wilt le at best a rtcurrinj, muMnee at
worst a disablnp iflUction md in which surj.cr> ImWs out
the only rcisonable prospcvt o^ comp’ctc cure—! am etc
0*1*1 ^ III-?*
Urrttt as
U-def I r k ind OivK** « M t t J h ' * P'" 11
AnJfVi l M -t-.'f rtf 7fcV \ l*>35 38 4'
I imp Alisccv's after riccIro-convniWve Tlicmpv
Sm — I have read with interest vour mnotation (15 evnaber
16 p 1577) hut I Ihmk tint it would he unwise to assume
Ihil i r incidence of this comply ition is umvcrvil
Pulnaoniry absLCss is indeed a serious comphcation md it
seems strmK that if one c isc in every hundred is liable to
be iffcvlcd so lillle attention has previously teen focused
on It Conw av md Osmond (19, s> report one case and
quote Kahnowski (19163 as siatinp that there is onU one
other i. asc in the hlcrauirc In his comprehensive review of
shock therapy Wilcox (19tS) states that pulmonary absevss
his Icen a complication in some clinics but cites no
rtfcrciKcs m British or AmcriLan literature In articles
dvalUH with the technique compluations and results of
electro convulsive therapy (F C D I'llmcr (194M and D^x
(1919) make no nacniion of this specific complication
In over ^000 eases iitited h\ LCT — ic double the nainihcr
qaiotcd bv Kwalw isstr e! «/*— f have cncoumcfctl nn abscess
in onlv one patient nnd even in this ease It was not possible
to nttnbuie it enurcly lo I CT ns the patient had had a
dental extraction under general nnacstbcsn a week before nclrnis
sioia to bospitial Almost without exception, cverv ease an this
senes was followed up for nl least n scar Atropme was nol
used but the patient was turned on his left side ns soon as the
dome singe icrmmated Temperature chnrts were kept and if nnv
suspicious rase w as noted or nny rcspirniorv symptoms cxlubitcd
the paucni was seen by tlic consiilttani physacinn and tbc chest
X rayed
There seems little doubt (hat the mcidcnce of lung comph
cations during or following HCT insulin shock therapy or
Jan 6 1951
correspondence
Bumsii
Mn>iCAt JotncsAL
41
prolonged narcosis is inversely proportional to the standard
of nursing In one mental I ospital m this country it was
found that following the e treatments pneumonia had
occurred m six men whereas no such complication had
arisen during the same period in treating twice as many
women When specially trained male nurses were allocated
to the centre the incidence of pulmonary complications fell
rapidly
As the last paragraph of your annotation raises much
wider issues may I as one who his used E C T fairly exten
sively since its nccption in this country be permitted to
express my personal views On the basis of experience in
treating a large number of patients I feel that out patient
treatment should be given only in exceptional cases and that
the practice of admitting patients to hospital for ECT and
sending them home in a fortnight or so is to be deprecated
Even when few treatments are gnen a mild cumulative con
fusional stale may occur during the early consalesccnce
period The patient is perplexed and worried for a day or
two but if medical reassurance is not immediately avaihblc
a rehpsc often results It is well worth while to retain
patients in hospital for at least three weeks after the last
electrical treatment has been giscn TTic highly charged
emotional aura surrounding ECT has in the past prevented
a balanced and unbiased generil esaluation of this form of
therapy The late Dr C C Burlingame (1947) that notable
advocate of tolerance and mutual understanding among
psychiatrists has however summed up the situation as
follows Only a stupid person would decry shock theripy
as an instrument in helping (he mentally ill but to
proceed as if shock therapy any more than any other
psychiatric technique can usurp the place of all other
therapies is psychiatric nonsense — I am etc
W LIDDCLL MrLLlGAN
REfTWENCtS
Burlingame C C 0947) / Amer mfd Ass 133 971
Con>Hay ti and Osmond H (1948) J ment Sel 64 633
Dax E C (l®4<>) in Rees J R (Editor) practice hjPs}c/iofct{ca!
Mfd! tne p 357 London Butt«rv.ofth
KalinoN ski L B (1946) quoted bv Con»ay H and Osmond H
Palmer H (1948) in Hams N G (Editor) Modern Trends In Psyef-oiogteal
Medicine p 217 London Buttcr^orth
Wilcox P H (1948) in Sptegel E A (Editor) P ogress in Neurology and
Psichiatr} 3 363 New York Orune and Stratton
avoided Ihen the patient could have been safely tided over
with morphine for the next two hours and the usual
abdominal delivery of the foetus and placenta earned out
follov^ed by a subtotal hvstercclomy I assume that plasma
IS available in Ibadan — I am etc
Church Village ROBFRT HODklVSOV
near Pontypridd
Manubno<stcmal Joint in Rheumatoid Arthritis
Sm — Experience with Dr W S Tegners patients in the
Department of Physical Medicine of the London Hospital
confirms the views of Drs A Bogdan and J Clark
(December 16 p 1361) and supports the statement by J J
Conybeare that in rheumatoid arthritis any joint may be
affected
Sinfe September 1949 11 cases have been seen of involvement
of the manubno sternal joint in patients knovvn to be suffering
from rheumatoid arthritis Of these only one case occurred
in a man There appeared to be a seasonal inadcncc as two
cases were first observed in September three m October and two
in November 1949 two m January one in April and one m
May 1950
As the authors point out the pam has to be distinguished from
other causes of chest pain and one of our early cases had been
submitted to cardiovascular investigations and a diaphragmatic
hernia had been considered In this region not all swellings
which arc lender arc necessarily due to rheumatoid arthritis and
lender fatty sweibng may be found lying over the manubno sternal
joint
Two further points of interest were noted in our cases Seven
out of the 11 patients gave a history of cough and five of the
patients also had involvement of certain of the costochondral
junctions with local pain and tenderness and swelling In three
cases the left third costochondral junction was principally
alTecicd In another young woman with active rlicumatoid
arthritis but with no involvement clinically of the manubno
sternal joint there developed such a marked swelling and tender-
ness of the left third costochondral junction that the patient
was afraid she had a growth and was only reassured when the
swelling subsided in about even weeks
— I am etc
Loodoo E ! M Q BiRKBCCK
Treating tlie Ruptured Uterus
Sir — I have rend and rc read the article by Dr A H C
Walker (November 25 p 1205) describing his method
of dealing with a ruptured uterus occurring in labour It
appeirs that he inserted his hand through the rupture
earned out i podalic version In the abdominal cavity and
then draeged out foetus and placenta through the vacina
A vaginal hvstcrcctomy was then performed and the patient
died after three days
Dr Walker states that he carried out these procedures
because he suspected that the uterine artery had been
ruptured and that the patient could not survive until the tire
facilities were available — a matter of two hours Here I
disagree with him Jt was clear that the uterus had ruptured
some three hours before Dr ilker saw the patient — i e
when the pains suddenU ceased In rupture of the lower
seement bleeding occurs /rom torn sinuses and occasionallv
from the utcrint vein but rarely from tearing of the utenne
arterv and if anv sizeable vessel is torn then bleeding is
profuse the svsiohc pressure falls to ^0 to fO mm He in
about half an hour and the patient is exsanguinated within
one and a half to two hours unless the bleeding has been
deal with siircicallv This is in contrast with rupture in
the upper s-cment through the scar of a classical caesarean
section in which case the uterus acts as its own haemostat
when Us contents have been extruded into the abdominal
cavnv and time can be spent m rcsusaiation
In the case reported the blood pressure was 80/40 three
hours after nipture therefore she had obvaouslv not
nipturcd anv major vessel but was suffering mo‘“c from pen
toncal shock than from actual blood loss If rupture of the
utems h id been diagnosed from the history and the
abdominal findings and vaciral examination had been
Rcgisfj^rs
Sm — Why has no one stated in the controversy about
registrars that the vast majority of these jobs were simply
created in order to provide experience for young doctors who
had grown rusty in the Forces'^ The appointments were
made not to meet the need of the hospitals but simply to
remedy rustiness Surely therefore many of them ought
to be abolished five years after the war 9 The appoint
ments of house surgeon and house physician will then be
more instructive and responsible — I am etc
ColchcJtcr M E LA^(PARD
Sm — Only a short time ago (although long enough for us
all to realize the truth of what was said at the time) vour
leading article wisely pointed out — one might almost say
pontificated — the unsatisfactory terms of the National Health
Service both in administration and in the doctors role Wise
letters also filled your columns on the matter but nevertheless
as the appointed dav drew near a sudden scurrv for cover v as
mad« by all but a very few who remained outside the
Service How historv repeats itself Once again vour
leaders pontificate on the dastardly behaviour of (he Minister
with regard to the registrars and wase Htters appear For
the registrars encouragement I should like to assure them
that unless firm coherent cohesive and coercive action on
their part is forthcoming I 100 of them wiU find themselves
in the street verv soon I would further warn that
unless the consultants choose to support them thev will find
themselves facing a similar unpleasant shock in about six
months time when they will probablv receive the same
degree of comforting editorials and letters — I am etc
B=poa-oa-Tr st. R Ll'VT
OIUTUARY
Bwmn
MirxcAL Jo<,»»i4L
\2 Jan 6. 1951
Obituary
U a.(ef tx’ndoK {
Sir PHU IP PAM ON MB llChir
Sir Philip Pinion con'iitim; pitholoii'.t lo the SIiniitr>
of He ilth tlicti It floiirnc f ml on December 27
Philip N'otl Pinion w n born it Wirclnm, Dorset
and MIA cdiicited it H irroM lrinit> Collcpc Cmi-
bridge inci St fhomiAS HiHpitil He qinhfied in
1901 ind indintetl MB, BChir a icir liter After
holdmp the poAiA of hoiiAC p!i>sicnn at St TliomiAA
and hoiiAe Aiirf eon 4it Addenbraolc a HoApilil he
obtiinal 1 I oiiiA Jenner reACiri.h AeliohrAbip in pilho
loe> at hiA oMn old teahinp acIiooI ind i Gibion
rcAeirth scho! irship at the SocieU of ApotfiecirieA
He MIA then ippomtcd
iiAiAtinl director of the
clinieil hbontoricA at S'
Ihomi", but •horil)
iftctMirdA joined tic 'till
of the 1 oiidon HoApitil
Mhcre for nnn) jeifA he
avia chiijcil pi!bolo>iM
ind director of libori
loricA He ptibliAhcd a
number of inijvirnnt
piper A ind Mrote the
Mell bnoMn textbooV,
Cliiucrt PitrfinhnA the
uitliorAliip of Mhieh he
Atnred in liter cditionA
Mill) ProfcAAor J R Mir
r icV Diirinp ind after
the A-cond Morld Mir
Pinton idMAcd the MiniAlr> of Iteillh on the
CAtibliAhment of pitholopicil AcriieeA lo meet the
ncedA of the CMS and the detulcd bnoMledRe he
E lined ia he Ment iboiit the countri Acned him in
Eood sleid uhen phni hid to be nude for the NitionnI
Health SerMcc Man> mcdicil men ia mcII ia hjnien
concerned Mith hoApiliI idminiAtnlion tnuAt hi'c met
Sir Philip Panlon on Iiia aiaiIa to hoApii ils ind Iibori
torics and been imprcAAcd In Iiia cultured urbinit> and
hiA ittenlion to detiil cicn at the end of a lonr md tirinf
d I) He Acned on Acienl imporiint commiiiceA of
the B M A , including the Centr il Cmergcnc) Com
mittcc, the Ccninl Medic il Wir Comniillee and the
PoAlgridii itc Cdiicilion Committee J'or Iiia AcniccA
to the MiniAtrj of llcilth Pinton m ia I nil tiled in 19lfi
ProfcAAor J K Mirnct. MritCA 1 Insc Acen the
groMth of the clinicil hboratory of the London Hoa
pint under Sir Philip Pinton a direction from 1909 until
he left in 194f) He had found \cr> hiptn/ird irringc
ments when he cime but he tjuicblv hid orpim/ed a
Iibontory thit wis ible to copt Miih anj demindA
that clinical medicine mide it tint time Under hiA
guidance it his continued to meet the c\er rrowing
deminds ind to undertake rcscirch o\cr i Mide field
Sir Philips interest wis in medicine as a whole,
liborilory work to him was in aid in the understand
ing and dngnosis of disease ind the treitmcnt of
patients His book Clinical Paitiolog) which first
appeared in 1913 showed his outlook it did not as
did most books of thit time include i multiplicity of
tests good and bad but only those that he had found
useful It was compiled almost wholly from his own
experience — written, as he told me, in bed in the cirly
hours of the morning
In those days ssith a less croMded course students
Mho wished to could nlc i post as clerl in the dim
Cil libnritorv I tool this post in the hot summer of
191 1 Punton made those three months most interest
inp md silinble like mmy others I hive owed a
grcit tleil both then md in the \eirs after to his
intcrc t ind cncourit,cmcni He mis tinustialK ibic to
appteciite other piiplcs points of sicw m scientific
mitters and to reili/c the silue mil imtiorlmcc of work
tint MIS not in his line and hid no immediate appli
cinon in dnpno'ts or treitmcnt This ind his general
interest in mcthiinc mide lum m excellent intcrmcdiats
between the mo c specnii/ed Iibontory workers md
cbnicims md between niedicil m-n md hymen
Sit L! ONARD PARSONS M D . F R C P
! UCOG, rR5
Profes or Hilili I lovd PRCOG wriies Siriconird
Pirsonss interests in the mlicil world were so wide
lint there is no bnnch of m'dicinc thit will not feel
Ills loss His contribiitjons to pacdiitrics were so well
rccopiirnl by the Royil College of Ohstctricnns and
Osmccologists thit he wis idmiltcd to the Fellowship
of the Colic) e in 19-SS and it tint time deliscrcd an
oiitstindmp lecture on mtcmial pacdiitncs His interest
in the cite of the ntwls born during the tim" he wis in
chirpe of them at the Sliicmity Hospital Birminchim,
hid the foundiiion upon which the present dcpirtment
Ins been built up AUhoiith his nstes in medicine were
citholic perInpA none of them were of grcitcr worth
thin this hiA own pirticuhr choice He had an uncom
mon facility for picking out soime p omisine juniors
and mmy owe i greit deal of their success to his help
and cncoiitaiement m the earls disi of their careers
So piAscA a greit friend of south md not imnatunlly,
one who retiincsl his soiithfiil outlook m ripening age
J C S writes Leonard Pirsonss life ssis like a rice
sscll run Ouiclly stcidfi'tls md moUestlj n went on
from siicccAS to success He siss carls that paedntnes
could nnkc greit contributions to the teaching and prac
ticc of medicine that it ss is one of the bulw irks agimst
cxsessisc spcinlism mil he designed bis circcr to those
ends In one of bis nre but delightful moments of self
confession he told me lint it was on a return journcs
from Amcrici sshcrc he Ind leirned so much tint he
SISS how m rnglisb hospitd michl design its ssork to
combine rcscin-li icichiiig and pricticc in m itmo
sphere of tonirulcAhip Ihose s'ho worked ssilb him
in Birniinibim ssill know best how quickly be did this
to nnkc liiA bospit i| one of the most fimoiis md h ipps
picdiitric LCnlrcA in the world But it wis obsious to
ill of UA ssbo I ntss him lint the aucccaa of his dcsicns
ss IA itbicscd as much through the ssirmth of Iiia chanty
iiA throuih ths cijcrncsA of Ills mind Hess is mils both
1 grcil physician and i bcloscd min In 25 scirs of
riptniiig friendship 1 ncser heard him speik ill of my
min, nor any ni in siy ill of him In ihcsc w lys he
Went on gilhcring fame, and alwiys a little surprised
tint It came is it did So many mcmoricA of Parsons
crowd till, mind thit it is dilTicult to choose but 1 shill
cherish alwiys tlic spontmeous kindness of his rtnnrks
to 1 youngi-r mm it the list meeting of the British
Picdi itric Association In that frmkncss of discussion
which has charnctcrircd the Windermere meetings the
young mm hid been somewlnt roughlv handled md
Parsons sprang to his defence with words of priisc,
advice, md cneouragcmcnl that enriched the day He
endured unfalteringly, so that none of us could belicAC
Jan 6 1951
OBITUARY
Burrait
MiCICJlL JotTLSAL
43
his age It was therefore fitting though tragic that his
life should end suddenly on a Sundaj morning when
he came home from his chapel, ^^armcd himself at the
fire and died
HENRY MacCORMAC CBE \ID FRCP
Dr G N Meachen writes I had not long been
appointed to the staff of the Blackfriars Skin Hospital
(then in the old premises in Stamford Street) when a
tall, pleasant looking young man cime one afternoon
to my clinic and asked, somewhat dilTidentlj if he might
be allowed to sit with me to see some skins ’ I quickly
discovered that here was no casual postgraduate hoping
to pick up a few crumbs of dermatological 1 nowlcdgc
but a real student of what was then almost a neglected
specialty, anxious and willing to learn all that he could
It was not long before I felt sufficient confidence in my
new clinical assistant to lease him in charge of an occa
sional clinic Thereafter I watched his upssard progress
with the greatest interest ind I rejoiced to sec him mount
the staff ladder at the Middlesex Hospital He was
indeed a loyal and lovable friend
L K w rites
Steel true and blade straight.
The Great Artificer made my mate
Henry MacCormac and 1 were close friends before
the first world war and it was sheer delight to me at
Wimcreux, where 1 was in charge of a hospital in 1914
to find that he was establishing a slin hospital at
Hardelot Plage some 20 miles away His work there
was almost superhuman and was greatly praised especi-
ally as he was able to send up to the front m a short
time manv hundreds of patients who would otherwise
have had to come to England to be treated He will be
much missed for not only was he a brilliant dermato
legist but a most amusing companion, sparkling with
that Irish humour which is inborn and cannot be
acquired He certainly had the courage of his convic-
tions and his great enthusiasm to carry a point was
always admired His quiet pcrsonalits was irresistible
and his smile at times insidiously enchanting he was
indeed a losable gentleman
Dr Alexs'.diir DALRsasiPLC McQueen who was for many
years m practice in Blacl heath Birmingham died at his home
in Birmingham on November 23 aced 74 years McQueen
entered Aberdeen University at the acc of 16 and graduated
M B Ch B in 1898 Before establishing himself at Black
heath where he remained for 50 vears he practised for a
short time in Oldhill Staffordshire He lived to see very
great advances m medicine and sorcery and could recollect
when major surgerv was performed in the homes of the
patients He vvas interested in Ihc worl of the St John
Ambulance Brigade and was the first d visional surgeon
and lecturer to the Rovvlcv Regis Division Well Inovvn as
an examiner at competitions in the West Midlands he was
recently awarded tie lone service medal He was a skilful
and conscientious practitioner to whom the welfare of his
patients was his onlv concern His somewhat austere
manner cloaked great kindliness and benevolence The
Black Countrv has lost one of us oldest and most able
practitioners and he wall be greativ missed in the distnet
where he wo ked for so manv vears Dr McQueen leaves
a widow and three dauchters — J P
Dr Ti'ioaaia Gerrvrd DEVirsEV d *d in Dublin on
Novemb-r 25 19'0 He gradu-ted MB BCh at the
National Unive'sitv of Ireland in I9-.I and h-!d vanous
hospital appointments until 1943 when he joined the staff
of the Grove Park Hospital I ondon It was here that his
interests became centred on tuberculosis and he quickly
showed an aptitude in the field of clinical research This
led to his beinc associated with the first clinical trials in
Britain of PAS and it is in connexion with this form
of therapy that his name is best known Thereafter he
devoted most of his time and energies to the study of this
new weapon in the ficht against tuberculosis He vvas
invited to visit the Continent America and India where
hu delivered addresses on his experience with PAS In
1948 he joined the staff of the Mayday Hospital Croydon
Here vvith his special knowledge of the chemotherapv of
pulmonary tuberculosts he instituted a new regime of treat
ment and inspired his co workers with fresh enthusiasm
in their difficult task He never spared himself at anv time
in his efforts for the welfare of his patients and constantly
overtaxed his own limited phvsical strength on their behalf
Finally his own health broke down in November 1949
During long months of illness he never lost heart and
his own keen interest in medicine did not diminish His
characteristic humour never failed him and when he knew
the end was in sight his courage was an inspiration to all
His charm and sympathetic manner endeared him to his
patients and colleagues and his death at the early age of
34 IS a loss to the medical profession as a whole and the
tuberculosis field in particular His many friends will wish
to express their deep sympathy with Ins widow and two
young children — L hi K
Dr Gilbert John King Martvn consulting physician to
the Royal Mineral Water Hospital Bath died at Paignton
On December 5 aged 81 years He studied medicine at
Cambridge and the Middlesex Hospital graduating M B
BCh in 1894 Three years later he proceeded M D and
also took the D P H After qualifying he became a house
physician at his own hospital and was later resident medi
cal officer at Queen Charlottes Hospital King Martvn
Went to Bath in 1898 and vvas in partnership for a short
tiac with Dr S P Btdd who died the following year
For nearly 25 years he carried on a large residential and
spa practice In 1913 he vvas appointed physician to the
Royal Mineral Water Hospital a post that he held until
his retirement in 1922 During the first world war he was
so over worked that his health broke down and although
il vvas completely restored by a sojourn in the Balearic
NIes he returned to Bath for a short period only and fin illy
retired from practice in 1922 when he went to live at
Draguignan in France King Marty n was a member of
the B M A and vvas president of the Bath and Bristol
Division in 1920-1 One of the eight founders of the Bath
Clinical Society in 1908 he became its president in 1913
He was a keen fishermin and was interested in the arts
cspeciallv painting and music Of distinguished presence
and courteous manners he was popular v ith both his
colleagues and his patients He was twice married his
first wife dying about 30 years ago — R W
Dr Arthur Edwin Rvinc medical superintendent of
Bishop Auckland General Hospital and part time assis ant
senior administrative medical officer to the Nev castle
upon Tyne Regional Hospital Board died suddenly on
December II in the hospital for which he had done so
much since Julv 1948 He was the son of R W Raine
J P of Middleton in Tcesdalc and he studied medicine
at Newcastle upon Tvne graduating M B B5 in 1916 after
a oistinguished academic career in which he obtained
honours in all his professional examinations Soon after
graduation he was on active service in Salonika and in
1918 he was invalided out of the R A M C suffering from
malarial fever After thi he spent a few years in Sund—
land in general practice — an excellent preparation for his
future career vith the Durnam County Ccunal and with
the Newcastle upon Tyne Regional Hospital Board For
2 j years he gave able and devoted service to the courty
U Jas 6, 19<;i
OmiUAUY
mctlieil olliccr in i.lnrj.c of its putilic ismOhhc mnlinl
scnicc! After llic Ninonil Itcilth ScrMic Net nine into
force in 1‘ttR Unne liitJ tno oiiisiriulinr profcvtionil
intircslr In lin iipuii) n meiliril Mipermirmlcm of
Holiop And hnd Geiici il lloipml tic dnl rtmte Itnn ms
oilier imlisniiinl to turn tins Itospilil ssnliin tint Omit time
from 1 poor 1 in inMitmion mil mfiriinr) imo in tuisc mil
sscll sfitleil pencril limpitil of Tboui '(Xl I ills wliicS is
nlrcnils ilcnlmi with n nnior stnre (if ilic nine lospmi
uorl. of ilic KXlOOt) people silio lisc in mil nroiiiul Ilistmp
Aiiil Imil It SI IS a (.rnt jos to Dr H ime lo sec this
npiil ilcsclopmcnl ami to Insc tlic lluhop AinHiml
General lloipit il rcio, ni eil bj llic licnetsl Niii'in>.
Coimet! as n complete reneral Irilnim s^liool for nm es
\Im) of Ins plitis imni nos' le soiiplftci! b, olliets bin
Ins ssisilom Ins assnreil tlie future simiss of tl'c liospitsl
winch helil such n siroiit, place in Ins allesiioiis Kmic was
ptoiiil of Ins unique appoinunem as pul tm e osMstant si-ni it
iilmmislritisc meilicil olh cr lo the rcponal liospiisl boinl
mil ss IS ttitcful for the opp irlinniv islnili it pasc Inm to
contimic Ins sersi e for the sshotc of Coimis [liiitisri Itis
wisilom ami Inossicil e were of the liiihcsl ssloe to the
hniri! in the plannmr of the liospiiil crsicc for Ins
complete anil iinimilc Inowlcilre o' the conms ami Ins
fricmlship with inniimeral !c i 'oplc in it tase to ihe
board m its earls >cars sornctliiri wlncli m> o'lier tl> ^to
m the repion soiitil tnse pisen His ossn chnicit interests
were in the c-irc of ih' arcs! sid. ami in ihts dim at
field he ss is sl'sclopm; i rood scraice in Ilisbop Vi.l
land mil eapedeil lo see miiili mine ainimphshcd in the
nest fess jcirs In addition l(> Ins olher onetons sliiltc'
Rainc ss IS atsis one of the oiiuml inciiiters of the llishop
Auchlind Hospital Manafcment Csniii' iilee ssliiili ossed to
him I pTcat dll t for Ins ssisc nmliti-c in the desdopmett
of the Olher tinspil ila in the ptoiip He ss is a inn of
great plissnnl mil ment il eiicrt) who did not spire Inmscif
m the course of liis dunes Init sitio found resteation m
music and liippiness in his church Ills sevcic ilint's s
few ssedks afo was Itierefore a great surprise to Ins
collcai-ucs and Ins sudden dcilli when he appealed to be
pelting user llic illness ssas a great sln'sli Dr Rainc
ihonplil seldom of Inmscif and jlssigs of oiliers csp'tiall)
the ued sich and Ins friends ind eoHeanies sjmpitfii e
ssith his sstdoss and Ins tssn btoiliers mil tsso sisters m
their loss — W G P
Dr Jons Rbssi It I ossr who died at se i on December U
while medical ollicer of the C In of Chater ss is a pradinte
of Trimly Collcpc Dublin ind w is Inmscif llic son of i
doclor A good sporlsmin he Ind pliycil tinbg for Ins
school Cimphell Collcpt Ifelfasi and (ns intivcrsiis and
ht had also rowed for Trinilj He ssas onl) yens of
age whin he died hasinj (seen qiiililied fniir yens In nil
his house appointments he not onlv sson for himself the
wirm esteem of Ins chiefs but the siry rcil gratiliidc of his
pjlitnts His loyilly and (cncrnsiiy lo Ins friends sserc
perhaps his most oiiislmdinp qinlilics Only tiuisi sslio
(new him well liarncd (kiss (inilini and iinosienniioiis sscrc
his many iits of hindness ({is trjiic dcitli it Ihe oiilsil of
a most promising ciricr comes is i grcil sfioih to Ins
unusually many friends — R \V M S
G B writes A member of a family who ossc much lo
the shill and care of Dr Robert Young AilV.cn Isshissc
obituary nonce appeared in the Journal of Nosember V
19501 would like to record that many pilienis will remember
him no (css for his Kindness nnd generosiiy — qnililics oficn
hidden by a pruffness of m inner In remembering him as
he wcnl about Blackburn and Ibe surrounding district in
those hard pressed days during ind after llie first world
war a vivid picture springs lo mind of the nil ilert Slot
leaping from car to door and back apiin for those in
real need Dr AilKen put himself to endless trouble 1 here
must be many who will think of him wiih grautiide
IS# mm
Mirsral Itraoui
Mcdico-Legal
SLUG! ON I INAI IS CII AltCD OP
M GI IGI NCI
[Igrut OLK Miriftn I ir sl Copprsro orvri
In 1') : Mr J 1 Whiicforil an American consutlinp
cnvineer of 05 si is lirci ired bs Mr John Ilunlcr lo bt
sulletinr from cancer of II c 1 ise of llic bladder On Iht
sltenjili of ibis dug nous be rclnrncd lo An c i a pse up
his p aiiiic pul Ins nlliirs in order and prepared lo d e
I lit Dr llenjimin Pirtintrr an Amencin siirfcon ssho ««
I im scsenl non lis h'er found that Ins di'*asc was not ir
fill 111 sh, net I Mr W inteford jeeo dingU sued Mr Hinlci
fe't dm lyts altc mg re|liic'’cc ip not inine a cssio cop'
•St prtf irnnn, a 1 lopsy Mr Jnstuc IlnVeli trying the c-se
at Inst imlaiKe in 19.#'! au rdrJ heasy damages bin lit
Coil t of App'il next ycir rest sed this judcri'ni and past
Mr WIntefoiJ lease lo jppsal 10 tb" House of I onjs Boh
healings sicie (idly repotted aid some comm-nt san the
e t was mad n a I'atlip, aiticlc in this Ji irojl' The r
lords* IPs Jlo has now jisen jii le-nscrl dismissing
Mr Wbitefodi app-al’
1 1 rd ('otter statcsf in (us opinion lint Mr VMiiteford*
atinnici s i\ not lint the dugro'is ssas r'ghetnt but 11 at
the rcscnllince betwe-n real and simii'atcd cap-er ssas so
close that ran d agnoos of canter slioii’d be accep 'J wphout
a pillol’i ell cairn niinm A suig'on nitst exercise Ihr
sicstec of skill and care tcasotuble fo o*'* in I is post
tion and si chitged ssilli nc|!i.e -e could clear bimscll
ly abosin, that Ic I Ml acted in acto dan'C with y-ncnil
aril app sssed ptawtiec Mr Hunter lad giscn csid-nce
siippoilcd b) |s\o eminent surgeons lint his action had
lonformed lia tin skilled r'ailiec of ihe p ofession On
the other hard fJ Barringer hid said that to serifs a
diignosis ia( a cancerous gtossih a complete eaamittilion
lay meins of a tsstos^ope ind thtoiyli the open blid.l"r
and a piltuslognal e'aminaiion |sf any questionable area
slimild hive b.en made that he took those steps himself,
lliai iltey were the ordiaata and mini steps and that there
was no di'hiiilts or ilaneer In either ispcralion
I onl I'orter lussicser did not think Dr Bamnccr meani
lliai air Ilunlcr sboiild hasc taken those steps in March
or April Ibe appeiransC and state ssf the bladder at that
time dill nm seem tis bi'c been disclosed to Dr Ramnper
sshose answers tlid nisi supicsi chat he had in mind the
imliinicd miss covcieil s'llti thickened mticoiis membrane
abnormal m eoloiir dcscribesl bs au Hunter but a condi
non liVc ibc scry shflcrcnt condition be himself had found
m New aork Moteoscr esen it bis csidcncc could be
accepted in full n spceinicn toiild ln\e been taken onls
with a cysioseopc fillcil siith a ronieiir attachment in instm
mcni scry rare m I nplind in I'Jd; and not possessed hs
air lliinlcr All ibe [ nghsti medical witnesses bad isscried
lint It ssas aeainsl npprosed ptacttec m (.npland lo use a
cssiosenpc where there was acute urinary retentton and
Ihil ssben Ibc bladder was drsmeil and collapsed tl was
dillietill or impossible lo use clfeciisely a cvsioscope nol
of the fiiisbing type Tins instrument also bad been rate
in I nplind it the material lime and Mr Hiinlcr had not
possessed one The appeal was dismissed hs unanimous
sole of their lordships
MOtg 2 sa? 1949 I S9S f69
'The Thun November 19 19S0
Persons wilbonl a selllcd way of b'inp (saprants or
cisiialsV in Dceember 1949 ascraped 2 367 in reception
centres of the Ministry of Nation il Insurance This was
the first time since the war that there Ins been a decrease
tboiieb all the post war figures arc low compared with
formerly
Jan 6, 1951
UNlVERSniES AND COLLEGES
n*rTtim 45
Mn? CAL JOLHSAL
Universities and Colleges
UNIVERSITY OF CAMBRIDGE
In Congregation on December 16 it uas decided to establish
T University Lectureship m the Department of Medicine
The following degrees were conferred on December 16 19*^0
MA — \V J St E G Rh>s MB BS Janet E Bottomlc>
MD FRCS MRCOG
The following candidates have been approved at the examina
non indicated
Final MB — *R H Adnan ^ *W V Agnew *P T Anneslcy
Armett * L J H Arthur ‘ N B Aikin ’R S Atkinson
A M Baker, A C Bamford *G S Banwell ■ >A P
Barefai Barton ‘A C Beatty ‘R J Bcnnison * ‘A P
Blower * ‘M H S Bound *J W Bradbeer ' S D Bradley
‘M Braimbndgc U S N Briggs ‘ *G S Bnndicy • ^P L
Broadhead * *1 M Brown * *W M Browne • *K Brown
Grant * *A A F Bryson ‘ * *W E G Buckley * ‘D M J
Bums P Bums * *A S F Butcher ‘ *E P Cadbury
' *M D Cameron C McG Campbell * ^P B Clark * *E R
Coats * *R A Cooper ‘ * P H Crosskey ^ *J C M Curnc
•*W G Davies • D G Dickson H Dickson M H
Dickson • *\V Dorrcll * G D Dowmes ‘M F Downey
‘*B O L Duke ’F P D Easby * U Fairgncve * * *R T D
FitzGerald ' *R M F Fox ‘R T Gaukrogcr ^ *A E Gibbs
*D C Gibbs “P C Glynn Jones *L Golbcrg * Goodall
‘ *P H Gorodi * H Gough Thomas ‘D M Grant *I H
Grant * • A Gnmsliaw * *I M Guiver ‘ *A T G Gunn
’ B M H Hardman ^A M Hanngion * ^A S Hams
’ *D S Harry • *G Harvey Evers ■ *M W A Hawaid
J M Heaton • *J F Higgins ‘ ’U M P Hill ‘ * G Hirst
‘M Hobslcy • 'C A Holborow * *M L House ‘^R L
Huckster * *P E Huddy ’R G Huntsman * Hurst *A W
Johnston * *E W Jooes ‘ *\V R Juckes *R Kceley *J C
KcUej “M H King ‘R G P King •*! Kinross '*C D
Lace) * ‘A B McGrigor * K G P Mackenzie ‘R E Mackic
*J J McMulhn »C R Maddock • V J Marmcry »S E
Marmion »Mrs C M Maxwell * *l H Mills ‘K H G Milne
*J r Moor * D B Murray * *J H Newton *G McK J
Nicholl ‘‘D S H W Nico! E M Orton • *A Pancih
* *G G K Parsons * ’F S Perry * U R H Pinkerton
»H r W Pnbram * E J Purcell ’ P J Randle
*J R Rees ‘‘R H Reynolds ' ‘J M G Ritchie
*H M Roseveare ‘ H B Russell * *F C Rutter
J J H Rymer * H A Sanford ‘ ’G E Sayce • *J R
Scale *J H Sewart * *C Shaldon * Mrs E C Shore ’PH
Shorthousc * *I M Simmonds * * * H S K Smgha * G
Smallcombc * D Smith 'I Smith *J L Somcncll * E M
Sproston * *C M SnITord ■ P C Steel * * E Stokoc
J D E Strong ■ Sunderland ’^P H Swinhoc ‘G A
Taylor K A Taylor * ’B E L Tliomrsan I G S Thomp’^on
P Tucker ‘B V Tyman * 1 M ^^atls >\V G \Senlcy
Mrs J M ^\cston ‘ *P H \\hcclcr * *Mrs M P ^^'hltchousc
■*! H ^\llllams *J A N\illnm5 ** R A Williams ‘R T
Williams **>D H M Woollam ‘ * *G H Wnght
‘Passed in pathology and pharmacologv ’Passed in principles
and practice of physic, ’Passed in principles and practice of
surperv Passed m midwifery and gynaecology
UNRTRSm OF EDINBURGH
\t a Graduation Ceremonial held on December 15 19*0 the
following medical degrees and diplomas were conferred
MD — r D Caldwell T M Chalmers E N Moves ‘C S
Russell *J T R Russell ‘J J Stevenson
M B Ch B — H F Achesen SN D A Birch G ^ ChcMie
Phvllis Connor B S Dorfman I A Fraser A D Gentle J
Grant E R Henry Brenda M Johnson Hazel M Lazarus
Margaret E Loudon A M„caula) A R Manners W P Mazur
J \ Miichcl! P T Monard R Renton P F F Rushforlh
T M N Salves L E S Sandnon G A Steel** J F S ephen
E B T„goe Nano M Twrcdie Siodart M,.r> B Watson J S
WTiiitakcr T W Wilkinson
DirioMK IV Mtdicvl R.iniornrK.vpa — J D Abb tt
TIic followang awards were m de CncI ton f\esea^eh Sefo^cr
rt p \ D Ro''*Tt'''*a MB Ch B Eth con Fr^ecreh sHp
S R Mukherpr B-. B,S Grorze Gtithr e Rcjrc^ch Fr^icm
ip tn Cht'd Hre^ h H S Prcvis, M B Ch B He i oh
Rc<c‘^J Schc in sm B Cru-wkshank MB,,
B r*. rr^ 7- Tf;nr ;'-e 5afrr*7- A B WJLce
MB Ch B /trirrn Gr-h^-n Rt hte Bun^r'ics D B E~ on
a"! N I M Browne Rus e -Cnz^tof^ Pn r K Wood
‘In ab«o** I- Cc’—’'-**d*d fo-
UMVERSFFY OF DUBLIN
School of Pinsic, Trimh Colitgl
T he lollowing candidates have been approved at the cxnmmaiions
indicated
MD— R W Barter MTS Conradic B V Earle H Fitz
Gibbon J M Johnston
MAO — C L S Archer M B Fhnagan
MB— -L Tarlo P J Myles T H Bcwlcy A C Allen H A
Dcvlin R W Mitchell J P B Tuohy R S W McLnmon
D L Cowan N I uriong Sara K Mitchell D D Macdonald
N R McNutt
BCh — A T F (Trench O Carroll Helen M Hackman
PEA Blake Knox Anna J Ilcndly M J Sweeney J N
Cocknil J O Hunter AWL Pollock A Rosenthal I H
Moore E W' Lillic R W' Mitchell L Tarlo D Romnev
W' G Hutchinson D D Macdonald J P B Tuohy
B AO— 'Grace M F ^orke 'R V Lea 'W McC Wilson
H J Ncctliling Sara K Mitchell AWL Pollock N R
McNutt
TIic following medical degrees were conferred on December ?
1950
MD — R W Barter H FitzGibbon J M Johnston
MAO — C L S Archer M B Flanagan
MB BCi! BAO— A C Allen T H Bcwlcy J N Cocknil
H A Devlin N Furlong Helen M Hackman Anna J Hcndly
J O Hunter W G Hutchinson PEA Bhke Knox R V Lea
E W Lilhe D D Macdonald N R McNutt Sara K Mitchell
F H Moore H J Nccihlmg A T F flrcnch O Carrol! D
Romney A Ross M J Sweeney J P B Tuohy Grace M F
Yorkc
With second-class honours
UNIVERSITY OF DURHAM
In Congregation on December 15 1950 the following medical
degrees and diplomas were conferred
MB BS — Meryl A Chnstnn J A Eykclcnboom J R J
Glavina C St J L Harding Mar)oric Hepple D D Hobbs
Shirley McTaggart B Metcalfe Shirley M C Nuttall Loh V
Stafford Anne W' W'ails
D P H — J F McGanty (tn absentia)
Henry Haney Evers MS FRCS Lecturer in Midwifery and
Gynaecology in the University has been appointed to the Chan
of Midwifery and Gynaecology at Newcastle upon Tyne
UNTVERSIYV OF LONDON
Dr Vernon Frederick Hall Ins been appointed Dean of Kings
College Hospital Medical School as from January 1 in succession
to Mr Harold C Edwards who has resigned and Mr Alexander
John Henqt has been appointed Vice EJean
Mr r Bcrgel PhD D Sc will deliver two lectures m the
physiology theatre University College Gower Street WC on
Thursdays January 18 and 25 at 5 15 pm His subject i'
Physico chemical Properties and Pharmacological Activity of
Drugs
Two lectures on Cell Metabolism and Chemotherapeutic
Activitv will be delivered by Mr T S W'ork Ph D m th**
physiology theatre of Univxrsiiy College on Fridays February
and 9 at ^ 15 p m ^
All the above lectures arc open to m-mbers of the public
Mr W J Cofictt will deliver a lecture oa Population
Trends m the anatomy theatre Univcrstty College Gower
Street W C^ on Thursday February 15 at 1 15 pjti ,
A lecture on Counting Heads — The Taking of the Census
1S01-I9X] Will be delivered bv Mr A J Taylor m the anatoms
theatre of Univcrsi v College on Thursday March 1 at I 15 p m
Dr E A^hv^onh Underwood will deliver a I'*cturc on John
Wesley nnd his Pnmitivc Physick in the anatomy ibcatrc ol
Uni'crsitv College on Thursday March 8 at 1 15 pm
Admission to th** above lunch time lectures is free withot
tr ket
Th** title of Professor of Clinical Patholo'w in th'* Univc^jfv
has been conferred on Montagu* M-izcIs M D M R CP
The foMowng candidates have been app oved at th- exami-a
lions indica ed
ACVO'VtlC POSTCXVDLVTE DlPLOMV LV MeD CVL RaDIOLOGV
(DuGvosisl — M M Craig
ACAOrMC PO^STCPADUTT DiPlOV V IV 'TrrvirxL PADOLrx*V
(Tin'pvpa) — H S Ah R J Di 1 on A W Pegh- s
Prefer- A W Daw-"!- p ofcs>o of h ** cno’''''v n tl-
Ln vc-sit' cf Liverpool wah d-’iv-r a S'v-C’al U'Tve- v Le^urc
on Irfee on and It — v m S—- 1*nox t‘’- I onden Sc^-aol
Hvr— *•- and Tro"i'^l M-d a^c k epp^^ S r— ' Go#-— ■ S -n
Londcr* W C on Fnd-v J --arv 26 at ^^0 pjn
•16 Jan 6. 1951 UNlVCRSlllES AND COLLEGES emn,,
_ _ l-fftnciL /oLiHit
A (.ouinc of two ipcciil Itnitcttit) I cclurfi on lltc Itohliiin
rtopctlici wcl I uticlioiM of t(ic Vitnmfitt II,, will (<<; dflncrcd
hy Ur 1 I cslcr Smilli ni the School of I’lntmicy 17 llloomt
bury Soinrc W C on Wcilnewl ly and IIitirMliv I cbrinry 7 and
S at ' If) 0 m
A ipetiil Unnettitt I r tine on 1 oin. Acid mil Gtowtii of
Tiimoiirc t^pccnlU Itoiit Sinonn will Ic dclncicil by I’lo
lector J f nrcibicih Hoini ptofettor of pithoIorLil mvomi
In the hnnciMiv of ropfnhi,rn at lie 1 omlon School of
llcpiene mil Iropcal Medicine on Mondu Iclruiry 26 at
1 10 p in
All the aboic letliiict arc addrened to t!i denn of tli- Uniter
lit) and to other inlerc ed in tl ' nil jeett Adni tion It lice
witlioiit tichet
Medical News
Kesc'ircli on Itilirrciilotit
The innii il report for IO<0 of llie llritiOi 1 til etciili tit
\ tocitli nit teti Itch comniitlcc iccoidt i tmtll pilot tit il
utinp thiiwcniairb iron- on adtTnceil pt Imnnary lub-tcti
lotit Allliotith scry popiiltr in Cictntiny tli t drnp I'lNt
not ipp ir from pnhlitheil rep >rlt to le mtihinp hie at
efTcclisc IS St cpioniycin Hie trtil conlirm'd the e pip is
to the cMcnt of siicp'tlinr that lino ^miotba/o i- no, hi find
Its tell Use IS 111 1 l|iirc ssitli sticpl ni'ycm when ;i i
inunnsalies he acid could nnl Ic fitcn A fuller controlled
inscsiirilion It plinncd Ilic ct'nimillec K nt o mallnp t
siirscs antonj, sliid-nlt of I oiulon ni died schOi Is and ttr
chest clinics lo deierniine tsliclhcr liislopI ismoti* is end inic
in flrilain
financtil Aid (o I’rlsalc Pnllenls
Die Motpital Sets ice I’lin in esitlciicc for nun) yetis
Ins 1 ecn modified lo suit pretenl dty condiliont Anyone
stibscnbinp lo ihit irtsiirinre fond and t ho is a pnssie
w ird in patient may recover the whole com of liotrilil md
profession il fees up to i maximum of £210 in any scir
Refunds are ilso mule apiinst Ihe cost of full im e hi n c
nursing and conlrihiilors who ire icnenl w ml S JI S
pilicnts arc dso cniiilcil to ccriiin I cnchls Ihe inniul
Mibscriplion sines from £2 lOt lo 10 nunc is depending
On the dcerec of cover and full dcljils miy Ik oMniited
from Ihe I ontloii Associalion for Ilotpilil Vnicet
Tasistocl House Soulli lasistocl Si|iurc 1 ondon N\ C 1
Macs R idfogripht In I Ire
Accordinf lo a rcporl in Ihe /rri/i Thncj the U-pirlmcnl
of Health his just created a limilcti non profil mal ing
company called Ihe Nnlional Radiograph) Associition
which will provide a mimber of mini ilurc mass radio
graphy mobile units to operate llirouchoni I ire svliercvcr
the locil he dill amliorilics desire them and eonlrihute lo
the fin inccs of the issoci ilion II is hoped lint evcntiially
all ire IS will wish to lalc adv iniicc of the service vsitich
IS modelled on llial worlini in Sweden Al the niomcnl
mass radioeraph) is aire idy conducicd m Uuhlin and in
Count) Corl /
A Dannnion I cctiirc Tour
At the invitition of the I’oslgr idti itc rcdcritions of
Aitstrali I and of New /c il mil Dr \V N f'lcklcs of
Aysgarlli yorlsliirc it diiriMg (he firs! half of Ihis year
giving a senes of lectures in these two Dominions
Dr Pickles will be away from Jamiiry 18 lo June 20
In Uriel
The new president of the /'oological Society of T ondon
in succession to the late Duke of Devonshire is ndd
Marshal I ord Alanbrookc
Professor T Tcrtiison Rodger is chairman Dr A Dick
vice chairman Dr Hunter Gilhcs secretary and Dr M M
Whiltet treasurer of the Association of Psychiatrists of the
Scottish Western Region for the session 1950-1
At the annual general meeting of the Dritish Association
of Plastic Surgeons on November U 1950 Mr A R
\V tllxcc (I dmhiirgh) was elected prcsu'enl Mr R J V
tUlifc fl ondon) vice president \fr R P Oibornc (User
pooll Itctsiirer Mr J P Pcidy tl ondon) secretary and
Mr A I) Wall ICC editor Ihe mcmlcrs of the counni
ire Mr J N Ilarron Mr O M I ii/Cii(ihon Profesor
( V Kilncf Sir Archibald Melrdoc Mr J S Tough and
Mt Ram ford \fowlcm
On Decepil cr II Ihe Uniicnil) of N irc> conferred o-
I) Htock Chisholm Director Gener il of tlic World Health
Or,ani/aiion Ihe de,re- of d Ktor I otuirn laiut of the
Univci'ity and of the Med eal 1 actilis
fh- Roy d Colic, c of Pliyuctins ) is preptred a list of ah
the <eriil pitheaiio i including year hooks contained in
Its 111 rirs s hitli sp cialires m Ihe history of ri eJici''e
Mills
Dr \ G N Well' c head of S'rciford lares lit
£11548 I) H li Morns It c M O lo Mils dl and We l
(In mssi h dislti IS ‘eh lo! Icfl £U 7H Dr W T At dianif
of Osfo il £2*059 Dr II Divlrm of Shorefarahy S- a
£21010 Dr Join kliln of Sini'erltnd £K-555 mi
D John Clifke lite of Rotherhtri £2-172
COMING IMVIS
Rolieil Camphell Mrttiorbl Oration
\ Ivsit jjt ( ottp‘'clt Mci t 'tul O 1 ion svill Is- given b'
t letitcnanl licneral Sir Wdlivm SfacStIftur in the G cat
Hall I'f 0 ectiv L'mse sily Relfi oa Tliiir<d.iv January
II at Sip pm His sub cc Is \ Medual Sirvcv of Ih'
Irish ! imire of 184'
Goiilsfonlan I erliirrs
Dr H J Ardftvon will d'hver ih' (nuilsioman I Ccltires
Kfote the Royal College o' Physt laiiv of I ondon (Pali
Mall last SW') on I tic slay nnJ TItursJav Jnnt-trv 5*
and II it 5 pm Hit stitjftl is lul-riulnsis of lie
Pcricirditim
lirltlsli l’ov|(.raduale Sledicnl 1 cderalinn
Ihe llniish PoMiradiiale Mcilicil rcdTtlion (2 Gordon
Sniiate I ondon W C) his artin,cd a nil nl-T of lectures
on He Scicsiifi lltsis of Mciluine co-npioitit the
second half of ili' series win h le^in in October 19^0
It) le delivered al the I on lot School of Hvgiene anu
Tropi-il Sledieinc Kcpp"l Slrce Gower Slrcct WC on
Tuesdtvs and Ihtitsdass from Jamiitv 9 lo March 20 al
' 10 p m The Iceliires arc deM,rcil cvp ciallv fevr research
seorkers and speerth'ts in Ironing anti ml nission is free
witlioul Iickcl D'lails Will he piihhsl ed in tlie Societicv
and I ccliues column of the Jotirnil week h week
Psychhiric Aspects of Acrnmegnly
A public leciurc will he delis ered by Professor Manfred
nictilcr of the University of 7urich nl Ihe Institute of
Psychnlrv M iiidsicv Hospital Denmark Hill 1 ondon SL
on W'cdncsihy Icbriiarv 14 ai 2 45 pm His subject t*
Acromegdy and Acromcgnloid PvyclunUtc tnd Genetic
Aspects
I citsumi in I cclures
Dr S Cochritnc Shanks will deliver Ihe 1 ctlsonuan I ec
lures before the Medical Society of I ondon (I I Chaudos.
Street Cisendivh Square W) on rehriiary 19 and 28 and
March 5 at 8 10 p m
Osier Club of r ondon
rite next mcelmc will he held it the Medical Sociclv of
I ondon 12 Cliandos Street, W1 on 1 ridav Jtmnry I9
1951 It 7 45 for 8pm The meeting will be in honour of
Sir James Cnnllic the centenary of whose hirih falls on
Jinunry 17 II will be opened with i biographical account
by UciitcnanI General Sir Ned Cantlic Director General
Army Medical Services The discussion will he- opened
by Sir Philip Malison Rahr and Mr I D D Davis
There will Vve a meeting on I riday March 10 1951 when
Dr Hugh Sinclair will read a paper on the history of
mitrition i
Jan 6, 19S1
MEDICAL NEWS
PjLrmn
McrjTCJLL Jo 'ILM.tL
47
Hcbcrdcn Socictj
A clinical meeting of the Hcbcrdcn Sociclj «ill be held
in the McNcrstcin Theatre Westminster Medieal Sehool
Horseferry Road London SW on Wednesday Janiiarv 24
at 4 pm when many of the cas-s shown prcaioush will
be demonstrated again after one leirs progress together
with new cases Dr J H H Cilsn for Dr W' S C
Copeman and Dr Oswald Sasacc wiU show a short film
on The Therapeutic rtTecIs of C ortisonc
Nutrition Society
A meeting of the Nutrition Soci ii will be held at the
London School of Hygiene and Tropical Medicine Keppel
Street Gower Street WC on Siturdaj J-'nuary 20 at
10 30 am when there wilt he i discus ion on TlieXiom
paratnc Merits of Animal and ScLCtahlc Foods in Nutn
tion Tile speakers ssill n Dr Tristram (St Andrews)
Dr Carpenter (Rowett Instiuit i Dr Blaster (Hannah Dairy
Research institute) Dr Y lies iRothamstcd Institute) Dr
Lucy Wills (Royal Free Hospital) Dr Harncttc Chick
(Cambridge) and Dr Dc ms (Cambridge)
Bnlish Association of Physical Medicine
A two day mcctinc of the Briiish Association of Phssicai
Medicine (45 Lincolns Inn fields 1 ondon W'C) will be
held on Friday anJ Saturdai April 20 and 21, with the
following prosisional provramme April 20 11 30 am
lecture-demonstration on Micro waacs by Dr A C
Boyle 2 15 pm meelinc at Headley Court Rehabilitation
Centre Epsom 7 for 7 TO p m annual dinner at the Royal
College of Surgeons of England April 21 9 30 a m annual
ccncral mcctinc 10 30 am short papers 2 pm demon
stration on Ultrasonics Further information may be
obtained from the honorary secretary of the association at
the above address
Medico lAigal Society
The annual dinner of the Medico Legal Society will be
held at the Sasoy Hotel Stnnd London WC on Thursday
January 11 at 7 IJ for 745 p m
SOCIETIES AND LECTURES
A fee is charged or a ticket is required for attending lectures
marked • Application should be made first to the institution
concerned
Mondaj
fssTinTTE or Mn\idslc> Hospual Denmark Hill
I ondon SC— January 8 ^30 pm lecturc-dcmomtntion b>
Dr C Stcnrcl ^ v.
Mrmeu SocirtY of Losoos 11 Chindos Sireet Ci'cndisn
Square London V* — Januan 8 8^0 pm d^cu^sicn
Unfjtreefed DrrfJi FoIIo'n/n? Orc^fltion \o be muodu-rd
bN Dr^ Kciih Simpson and I\*an MapiH
^^T HosriTAi St Georpe s Circus Southwnrv. London
8 4 pjn, Opticz {RcMsion) by Mr H N
Reed
♦Rosal r^T IIo'iriTAt S Gcorpe s Cirais Soulhn-ark I ondon
SC — JimnryS ^,30 pm Arctomy of the E}e erd Orbit
b> rrofessorT Sjcol
TctsdflT
RRmcii Po'^TCRinuATC Mfdical Federatiov — \t London School
of Hvpjcne and Tropical Medirne KeppeJ Street London
V* C ianu^rv d 5,30 pm The Sxenificcrce of
r/:n/irr rr c Cftr'nfrc! Trc'iimiUer of the Effects of Amc
Sir Hcnra Dal- O FRS
CtirLsn CitMrM Socirrv — At ^uth Kcn'nrtcn Ho el 47
Quccua Gate Tcrmcc London S NN Jan\.arj ^ 7for7w0pm„
coloured cmervMoerarh film Dsr-tsh Exr^orrti'*n in
NcTjf-crn Green^crd to be de— ons rued b> Mr Ebbc MurcL
IMs^nmr or D RvuTOtocn Ude S ret Le-nr^cr Square
London V* C— J-nuar^ 9 5 pm„ The Fyoserc Co ct tn
Derr'^ t Vcr b^ Dr J O O’lTtr
Ro\al Coarrr or P^iY’itcjavs of Lnsix^v Rail Ma*) CaU
London SV» — januar. 9 5 p-m ** TuVrcu’ojfy of the Fert
es^d GouR o-i n Le'^i.'e bv D H J A^d '^on
Ro^^t r^T Ho«JTrrAU S- G*cr{r s Crrus. Sou h-«*a 1. Lo-don
S E — J-ni 9 * pTn„ Str^pr^ of ii e Fr ''re b\
Mr T M
T\edre<d^
OI\<nrTn.nT o^* ATOirvj’i Lis^* S e- L- ere* Sq*. re
Ic-don V* C — 3a-.i.*% 10 ^ p-n, \ rev Tr*^f q /e bv
I> C M kr— V
Roml V\r ffn^rrTAL. S s CTut Sou 1 Lc*’don
Sr ** Fr*n e- c! Fj*'0*jr*e b^
Mr R r C*7vJ.
Ro\al rActUTn or PuY'atciAN^ Avo SuRCroNR or GLAsro\\ 742
St \inccnt Street GtaA"o*\ — J'tmniy 10 ^pm 5>mrtoir^
tn Ccrdiac Diagnosis I mltison ^^cmorlal Lecture b> Sir Jo'in
Parkinson
Royal MicFoscoriCAU Socitrv TaMUoA Hou^c Sou h TqmUo k
Square London C — Jinuar> 10 f pm niectinp of Ibo
lopical Section ^ftcro dissection Sluates on imoch-^e by
Dr Joan torch
Royal Sasitary KsTinnr 90 Ruckmrham PMicc Road
London — January 10 7t0pm di^cu^iMon 7Ae//ricfif
of Poems in Dncf/mcr in Rcfnfion to Ifcnlth and Comfort
to be opened by Professor G P Crowden
Society or Ciir iical Imilstry Food GRour — At Medical
Soacl> of London U ChandoA Street Cn\cndi^ti Square
January 10 2 15 pm loinl mcctinp of the Microl loloncnl
Panel Viith the Society for Applied Bactcnolo^ S\niro<ium
The Ci/o’ocy of Uecterla 1 arerr b> Dr C Robmow
Mr C 6 Moms Dr F CosAlcti and Dr K A Risnct
Pfofc<sor R J V PuUcriaR syiH op^ the discussion
Tharsda)
AtrscD Adler MroresL Soritn — \i 1! Chanilos Street
London W j‘»nuary 11 8 p m A Gei rm» T/icor_> of Human
flehaMour b> Dr M G Good Discussion to be opened b)
Dr James Moore
British PosirRAOUATT Medical Federatio t — At London School
of Hjricne and Tron cal Mcdianc keppel Street I ondon
\V C Jamiarv U SiO pm Sreefnf Proftfemi of Chenucat
TronsmisJ/on o/ r/en p E/Tec/j 6> Acery 'c/io7nr Adrcnatuie and
btorairenaUne^ by Dr \V refdbcrp FRS
Dovcasttr MmtCAL Socinn — At the Danum Hotel Doncaster
January 11 7 for 7 15 p m nnnual dinner and dance tn be held
m conjunction v.aih the Doncaster DiMsIon
©IssTnxrrr or Dermatoiotv LhIc Street Icicester Square
London \\ C — January 11 5 pm Patholo}:} by Dr J O
OIiAer
IssTiTim! OF Laryvoolocy A' d Otolooy 310 Gra> s Inn Road
I ondon W C — Januara 11 5 pm Otitie Barntrattn o b>
Air Commodore C D D Dickson
Liv'Erfool Mepjcal Nrtitutiov 114 Mount Pleasant I i\cr
pool— January 11 8 pm papers Chemotherapy in
Tuberctthsis ' bv Drs O F Thomas R M Todd and C A
St Hil)
Physical SoettTY CoLOim Grole— A t Lecture Theatre
Tnstutite of Ophthalmoloey Judd Street I ondon VV C
January 11 5 pm $7th Science Mcctmt: Cofuiir I /sfon
Characfertstlcs of Ei:\nllan Trichrnmnls b> Dr I G H
Ishak (Ibrahim Pasha University Cairo)
Ourrs s U'»ivrRstn (Cpfat Hail) Belfast —Januarv II
810 pm A Afedicof Sunrv of the tnsh Pamine of
b> I leutenant Genera! Sir IVilliam MacArthur
Royal Army Mroicst CoiLrct — At I ccture Theatre John hhp
Street London SW Januarv 11 5 pm The SiRntheance
of Anaemia by Sir Lionel Ululb)
Rosal CoLtrrr or PirYstctAVs or Iokoos Pall yfall Fast
London SNV — Januarj H 5 pm Tithercidods of il r Pen
cordium Goulstonian Lecture by Dr H J Anderson
Royal Eye Hosfitau St Georpes Circus Southv.arl I ondon
SC —January 11 5 pm bfethods of Examination b>
Mr C M Shaflo
St Georges Hospital Medical SaiooL H>dc Park Com'*r
London SW — January II 4 30 pm Iccturc-dcmonsiraiion on
psychiatry
Torovay and Disttict Medical Society — A t Torbav Hospital
Januarv 11 430 pjn clinical meeting
Friday
•Royal Cvt Hospital St Gerrp** s Circus Southskark I ondon
SE — January 12 5i0pm F/njft7’o*> afther\r
Royal Medical Socim 7 Melbourne Place Edmburph —
January 12 8 pm, bfyocardiaj Ischaemia dis'-rtaiion bv
Mr Philip Kessl>
BIRTHS, MARRTAGTS, A^T) DEATHS
EtRTTIS
Mjt— D “cnN-r 17 19^0 it C'^aU'A’a Kcrt to Dr
dorr— Jr MacKe-n ) w tc rt Dr G A- (Ic^ 1 Mir *
ARRTACES
Oisawk— r*wcTtl.— Dn D-c-r*** If 19 0 at S*»r**t* 'ti’xn T»t5*
IVnirat \Nu a-i ta Rub ct Fayccii 't D PS
DCH
TITl— Pwwt,— O* Nio^c^Ner i*! 19 0 it ih- Pin h Oar N St
Fi 'r C?rk Jr*-- fem F j- HH »t B COi U7 Itijh Road
Leya*- E. to fjiTt: era P-m. O'" t at Sec*i Ork
McTray*— -O^
S-''— 'i-'d N i;:TTaT M
*vriL— |-
SFd L.Rrrscr«t
Oa D**er-S»^
CCTTlt. Edwi l3 V*Ti
r»a tm — O- D --1—
Pa kt Str NnC pi— ;
%»pzk»a.— 02 t>-cc~*'
0*n Te*'— _3
ar*d 41
TW r — Oa 0-c*r=-^ 1
'LB PO I Pi,k
DEATHS
19 ““ at S o '^-•cr^Avn- Do-^aJd
D Cd Terrs Co*jr* S *a’*C!'<J-r-vATaa #ra! 75
19 0 r — r* LOkid^s Sn* OBF L R C P A.
cf '*1,* ‘d % akc^^d
U 19 0 at I? Fz!r-“c*d Pcad Crtyiimi SrT*T
•-T QBE FP Ci! a* d ft
77 19 '' at 1:4 bcss* 0*^-*, Pa*! p/rr* Erd
- 'LB„ BCh.
■*13 19 9 at S'-Tr H'w-'ju Ci«s^raa Art** r
Va'-r'-s MB OB 3 n~» T , Cr*t
I at V t h-— JcYr S's:
Hicc A Plrarr^h
i V.> ^ OBF
LI'lDl MlOl OGY SI Cl ION
•iS Us (! 1951
ttrmti
Mfwcii
Ll’mi MIOI OGICAI NOT CS
Smallpot at ItilKliloiv
Up li' J ininr> 1 (6 pni) II c’tici of ^roillrttx incluflinp
one dc-tlli Im\c been rcj'ortcil in llic rcn"n of tlfijliion
llic infctlion II llioiijlii lo Inxc been inltodiiced an
RAI iitlKcf who Hew [(om Kifichi to 1 coebti' life
xhirc hndm^ there on Ninciitbei 11 I'i'O He hxd teen
nceiinlcd in Oaolier I'Ho [wo .h)x Inter he inxelKI
lo Urithli’n b) rail artel Uli ill riorini lie jonrtie} offer
inj, from nioix No M(nx or mniptonm (.luruicrKti of
nmdipon dex eloped tlioiiph he ix mo) to luxe Ind n xpnr r
nxh no* xeen hx i doeior and le win ticxtcxl xt Unehloii
for nnlirn lie xioicd friendx al llrtihi. n rrHiitievI fo
leiRlntx on December C xxeni to KinKox Mi'is^xhue
on Defend er It nnd then rctorncxi lo Urn h on on
D-Rrcmbef 21
Mcimifiile on Pet'rnbcr 12 a xxorian i(cd 27 txho i
he Ind been Mntin). fell ill She Ind lud ion)ii''xiixmx
for ixxo dixx nnd went x''l dol> xxn Id xcnxt '- 1 12 ttnxVxo^
thil the nnlxne lint xiitled on lint dxd xux due lo the
conjtinclixilix Mie xialexl at Iiort - tiniil Dexernbe H xxlen
n fexx xpx'Ix xtcxclop'd and xhe xxjx xcnl (o ho ji j| SitnII
pox xxax xluinoxcxl on Oceernter 2‘> Ihe raxh wax ar^pi j|
and Ihe x)iriplon x were fluid On fdxeeniler 27 her falter
aped « IX idnnftcd (O hoxpifxl xerj ill Viidi in efjthcina
loiix ind ti leinorrh ipic taxh he xlird on Id ernter 21
rmher nnd dun liter Ind leen xaceinxled onl> m Infancj
On IdCxeniler 2'> two n ore xa'ex 'xcre dninixed— a
xxonnn friend of (he dii!(h(er aped xfont 2< xxho Ind
helped to mtrxc her K home xml a nnn xiho Ind I ecn
uolinp the firtiil) On Ideicnil-er 1(1 one of the riirxex
M the hoxpinl d,.x eloped xnnllpox and xo x'rx the xamc
di> did I xxonun xorrer xiorhirn at i laon tr> (o txhieli
the oflierr X ilolhcx lud leen enl on tdicenxl f tt On
December 31 three more c-ixex xvere dnrnoxed -two xxomen
xotterx (tom tlw xime Ixondr^ and anoiher ntifxe it the
hoxpifal On faniiir) I xmal/pox >x u draprroied in i fhird
nutxc fxxo of ihexc ntitxex lud nexer leen xacematexi
and the tlnrxl once onl) in childlioo 1
Potlonijelldx
Notifications in the xxcel, endinj Idexembcr2'' Ifso xxerc
pard>tic 3S (R2) non piril)lR I' (2'*) total J3 <t07)
The fuiircs in piicnlhcxex are Iho c for the prexioiix xxeel
Uncarreilcil rioldic ilionx for Ihe corrcxpondmi xsccl. in
1947 nnd 1949 xicrc 60 and M rexpiClixcl) Total im
corrected notilie ilioiix for |9S0 to ind iniliidim; the xxccl.
under rcvicxx 0 x 8 643 TTic toriexpondinx finiicx for 1947
1948 md 19t9 xxcrc 9 1 17 2 3S6 and 6 79| rcxpexlixcl)
Coiinij ircas xxiih the laricxt nximber of notdnritioiix xxerc
I ondon 6 and I xxcx 6 flie ririrhed fill in the fipiires
cctuivaleni to a SO reduction conipired xxilh the prcxunix
xvxcl. IX very salixf>clor>
Infliicnrn
TTicrc his been a marked prex ilcnec of influcnri in
Scandinixn from cases of xiliich ri virit' (ns been txolilcd
not unlike the A prime slnin xxliich ocxiirrcd m this
country m 1949 The dixeast his hxen of a mild txpe but
with a hipli attick rale Ilipli incidxni.es of inOiicnri luxe
also bexn rcporixd xxithin recent xxxxks from xcrl <in pirls
of the USA Northern Spun Sardinia Persia nnd
elsewhere
In the absence of notification of influenza the incidence
of pncumomi ciscs and deiiilis from pneiinionn and
influenza are used ax a puidc to the prex ileiice of the
disease and the following figures may he xif interest
Great Towns j
1 pneumonh fnchidine 1 nniary Infltienra
Ca^c< j
Deoihs 1
Influenrat Dentha
Week cndtnR December 9
347
23r
3t
Week endjns December If
274
283 1
33
Week endins December 23 |
363
350
54
1 \\ *Iet
f (Pririary ind
Civet
Ue<V. »o } ff t)^tir t«rf 9
!
rrxsiA* |>«strr »vr tf
g IVver ^rr 2)
i M7
( iliex and lux nx xxiih the larpext number of pneumonia
nolihk ilom for llr xxceV ciidinp December 23 were
fsindon 4; Siind'Tfind 24 Ndweaxifc 23 flirminpham
20 Mxneliexct 17 Si eflictd |5 lucrpoof 14
Allhointi i)ir>e xijiiiiirx afford nt> cldTCe of an) lermiK
oiiiltrak o' I ifiiicr a in lliix eountry up lo December 2 j
in (fie lait xxc'*k or rtiorc the dneax-' lixx been scr) prcxalca
xn the no th eaxi and a rinl-c' of Utpc lovmx haxc beer
liti ineliiJ nr Sun ''tiard Durham nnd Sexxcaxllc upon
l)nc ft •cernx lilrl) (hat ih- xfixeao- hax spread lo l' n
area from V iruhnavn and hloralory x'udicx ma) j’mw
th" xiiii' X run lo l-e njcnli al xuih il at tn Sr-imhnaxra
tt e di'caxe tn the north eaxt app'xrs to he dixtinet from
the sr xallcd inlh ra a at p exeni xxidexp ead rn other parti
of tic lOimir) lie infec ma ma, sp'ead southwards ir
lie n'XI few xsecks
Uoail Sceldents
Aieiifdinp ro tie kfirix r, of Trarxport 483 people vxc'c
killed In load ac.i lc"U in (Ktob"r |9S0 ax compared xxi h
T‘0 in Oviol>ef 1949 Thme injured in road acciJenix ir
0 uiKt 19*0 numherc I 4 S4S x'tioi xl) injured ard 12S7P
tfiphtf) injurcif f oricxp'ird nj f cures for Owfober 19x9
arc t (18 and II S|4 U.loh-r 19*0 had the hipheii
liiiinie r o' n id caxinl les fo an) O lo''er since the xxar
In Nose ilet 19*0 the ptoxoional figure for deaths ix 484
>\teV J ndlnR DtccmhcT 16
tor drill cor<".iilixc xicckx th' mctd'rcc of d)'cnterx
hax tixcn in I nrUnd xnd \\ xlex and durmp the xxcek end
inj Dveemls-f 16 a new tceoid wxx cxtabhxhtd xxnh 1 2!4
tiolifi itmns A further rue ii* Ihe number of notrlimtron*
of nietxlex and iihi>opinr coiiph xxax record'd and both
ilirsc due lies are al an exxep'ionatl) hipti Icxcl for this
period of the >car \ lur xnx recorded tn the incid-rce
of xrarlet fexcr and aiutc pneutvoma but the staxonal
tiemlx of tbexe dixeaxex arc unuxuall) low Of the *0 cases
of dipMheria in Injlind and Wales 14 xxerc notified in
1 ancixlofc
The fill m the nolifualionx of aciilc pohom)ehtis xxax
clicckcil a rise of T xxax rceordcil and the total xxas the
largest number notified during an) liflieth xxcek TTic larpexi
of the loeil tixcx of acme poliomxchlix durinp the week
Were 5 m Siirte) and 4 m Kent in the latter coimix 8
of the 10 cixes were notified in Orpington U D
D)scnlcry
Ihc larjcst returns of d)xcntco dunnp the xxcek in
InjIind ind W'llex xxerc 1 im-axhirc 262 (Southport CB
82 Oldinm C 11 28 Rixhton UD 28 Irlam U D 2f
Salford CIl 23 Great Harwood U D 21 1 xxcrpool CR
20 Middleton M R tfil I ciccxtcr'liire 239 (I eicxster C R
196 M irkcl llarliorough R D 11 Harrow upon Soar R D
10) Torkxhirc West Riding 132 iLatb) U D 48 Saddle
worth U D 20 1 ccds C 11 10 Shelhcld C R 10 Rndford
C» 9) Shropshire 8a (Shrewxhur) MR 20 Whitchurch
UD 10) I ondon 52 (Ishngion 14 St Pancrasll) Surrex
17 (Mildi-n and Coombe M R 20 C-shtr U D IS) Durham
40 (Dirlmgion CR M) Miihllcses 40 (rdnionlon MR
29) Monmouilixliirc 40 (Ahercarn UD 20 Newport CR
15) Wirwicksliirc 39 (Ritminpham CR 33) Sotkslxirc
I nsl Riding 37 (Klncsion upon Hull C R 34) Cheshire 34
(Mnccfcxfictd M R 91 SiafTordshirc 28 (Clieadie R D 9)
Torkshirs North Ridinp 23 (Middlexbroiiph CB 15)
Norlhaniplonsliirc 19 (Corh) UD 13) Esses |8 (Rom
ford M R 12) W'lhshiri 14 (Marlborough and Ramsbiirx
R D 8) Cumberland 12 Glamorganshire 12 Glouctsier-
shire 1 1
Jan 6, 1951
EPIDEMIOLOGY SECTION
PufTmi
XtrvCAL JOLTtKU.
49
So «0
iNrccnous diseases and vital statistics
Wc pnni below a Sumnnrv of Infcchous Diseases and \ita1
Statistics in the Bnlish Isles during the week ended December 16
Fiinirci cifPrinaral Notifiable D 'eases f jr the '»e<’k and those for ihecorre*
sponding Week tail year for (a) Lnelard and VS ales (London inctoded (b)
London (adminisirat ISC county) (c)S<oi(ard (d)I ifc fr) Nonfern Ireland
Figures of nirthi and Deaths and of D ilhf rrer l^t u d tjch JnfrrtI ui
dlifa\e afe for (a) The 126 great t wTis In Cn land and VS ales (inctud ng
London) (b) London (admlnlitrati ccounty) (c) The 16 prin'i'^a) io«os in
S^tland fd) Tlie 13 principal Iomtis m Lire (c) Tb 10 pnrciniJ loisns In
Noni ern Ireland
A dash — denotes no cases a blanV pace denotes disease not notifiable
Of no return a\-ailable
Djscdte
1950 1
IV 9 (CorrcipondineWrek)
(«)
(b)
(c) 1 W) 1 (cl
(a)
(b)
i (C)
i(d)
fc)
Meningococcal infec
tion
Deaths
29
-
i !
14 1 1
37
17
3
1
Oinhihcria
Deathi
SO
4
-1
, - —
9‘‘
1
14
31
3
4
Dysentery
Death)
I 214
32
I47j
1-
197
13
73
z
2
Encephalitis aente
Deaths
6j
I
I ^ —
—
z
—
1
L
—
Erysipelas
Dcalh)
1 10
_
38
: to
4
lorccloe cnicrilis or
diarrhoea under
2 years
Deaths
ibI
1
10
23
,
18
3
Measles*
Dcaihst^
I4 223!i53-1]
~ 1
.35
157
2
100
1 793
34
37
57
136
Ophthalmia neona
torum
Death)
12
1
31
-
8
-
Paratyplt^'id ferer
Deaths
3(fl)
' —
8
I
—
' —
1 —
Pneumonia inflaen
sal
Death) (from in
fiuenra)
f84 36
33] 2
19
6
10
676
-41
38
5
15
i
1
4
:
Pneumopia primary
Desth)
:s3{ S'!
, . 72 !
U
t
21
25*
40
1 390, 33
i 1
tt
Poliom>elitJS acute
DcaihsI
1071 s
(
:i1
1
93
6
III
l|
1 1
1
Puerperal fever
Death)
7
1
1
-1
J 1
Puerperal pyrexiaJ!
Deaths
6f
3
Q
—
"3
1 ’1
1 ‘
3
Relanting fever
Death)
—
—
—
1 ”
—
Xcaflel fev-tr '
I>calhst
lOt
*01
37
* 9*9|
1
r?
2-6
Smallpot
Death)
I 1^49
I-
I-
Z
— 1
— 1
1:::
z
r>'phi.iJ fever
Deaths
— ‘
1 =
— —
—
—
—
1_=
TjThus feser
Death)
—
' 1 ' ~
—
i-
j-
i=
i
VV> v>'' *g<o' gh
n aihs
1 4^3 <*V ( 3
1 0 i' — — _
I 9«4, 3*. 6^ 26* *X
Oca h)(0 ! jear)
1 n '
.SI
1 VO 44 II
Deaths (estlu'* rg
s jl hmht)
A*n«al tS a h rate
(per 1 COD per
Si nt li ng)
‘ I 1
-* 9 i r
i ',>J i
5fO
S7S
t 1 1
: 679| IX*j 144
jt4jil<,
IJsT h
Ar— -al rate per’
1 O"'? persons
1. -c
1 « 4V I(» f. 1
! i
1"
6*JI
IC^ 5*^1 *4i IV6
Mi'
1 ii'3 14 1,
V 1
Ra t p- 1 tV.3
to «l Sn'* («•'
Ct i “ St ’
1 rj -
1
V t
ij 1
* Z-
'Mi
• Mr* i-s ii •A n-’Sj I t 13 Vur a-J i^r re -m» art -y-x as
t"**~r* '•'* 'T' or
♦ Dra H Irvvn r-t-a r* a“- *-a-*^<t fr'Tf f C a-d W- -v.
(a-***^ * nr ere.- I ■•i Ir 1 bp
1-1 a V f ~ I - a - VV a •*. - — e
COST- 1 a-'- N-n a— 5 W 1--
f rse • -“V c* <1** f"*^ •' » a-- f» ■‘-e-cf- ^ tj for to—
Ur a-d VV t\ s, L'T'-f ii-"c -» * ^ a r c»->^ o-\.
I l-v. ^ • pof-rc-il -’t f L i VV » rt a-r Ft
» p-ura-T pirors'C a CK? t*“f- 3- »*- r « t^e
Any Questions?
Corrr^ponJi’nfj should pne ihnr i arocs and aidrcs^cs (not
for puhUcation) and tr elude all rclexaft detaih in their
questions i\hich should he t\ped Hr publish here a selec^
/ion of those questions and arsiicrs y\hteh seem to he of
f,cncral interest
Alcohol after Head Injiin
Q — Hoi\ soon IS it rd\tsahlc to resume moderate drinkinp
after head in/»r> ^
A — DnnI ing rm) be hirmful to a piticnt who hav had
a head injiir> in two wajs (1) In ckcs of open vktill
fracture with penetration of the cerebrum post inumilic
cpilcps> ma> appear as a complication If it doev hciv'>
consumption of beer b> causing h>dralion may prcctpi
titc fits (2) A piticnt who has sustained a severe and
diffuse injury to the bnin followed b> a long period of
unconsciousness will often exhibit such svmptoms as
disturbance of memory power of conccntntion or
mood In the presence of such symptoms drinking of
spirits IS best avoided finally anything likely to pro
ducc headache m a patient with this symptom should be
avoided This in itself indicates care in the matter nf
alcoholic intake
Treatment of Malignant Hypertension
Q — A man of 55 \Mth lonq standinf* hypertension (UP
246 150) had a stroke three months oeo from h/jic/i hr
rccoicrcd one month ago he anokc >u//i a paresis of the
left leg which rapidly impro\ed but 12 hour^ later he
suddenly lost the sight of both e\cs rxaminatton showed
pallor of the retinae and constriction of the arteries and
there was loss of peripheral viwon objects and colours
could howt\cr be distinguished with diOicidt\ S’ow (one
month later) there is slight impro\emcnt in \tswn the
retinae arc less pale and the disks appear normal hot
are the diagnoMs treatment and prognosis ^ H ould hexa
methonuun hromijc or venesection be of \alue in this case ’
V — This man appears to be suffering from malignant
hypertension with episodes of severe vascular spasm He
should improve v\ith rest in bed a low sodium diet and
hcxamelhonium bromide Venesection should not be under
taken because it would do no lasting good and mirht well
prove dangerous In these cases the patient should be
thoroughly examined first partictilarly with rcgird to
cardiac and renal function The effect of sedation should
then be ascertained Hcxamcthonium bromide may th'‘n
be administered subcutan'^ously or intramtiscularlv in an
initial dose of 20 mg preferably with the patient in the
propped up position in bed A fall in blood pressure may
cause dizziness but this can be promptly overcome by
removing one or two pillo vs or if necessary by laying
the patient flat TIic second dose may be increa cd or
reduced according to the initial respons- Injections may
then be given twice daily \s soon as satisfactory con
irol IS obtained hcxamcthonium broraid- mav N- given by
mot ih up to a maximum of about 1 g three lirn'*s a dav
\oie — In reply to a question on the imm diatc treat
ment of an att-ck of hypertensive creephatopathy t Anv
Oj'*^*mns ’’ Novcnb'T 2^ 19^0 p 12 j^) the intravcrou
adrain s ration over a period of two minutes of p'^nia
raeihonium iodide or b'*xame ho**iun iodide n dos'-s of
•^0 me w-as rc-omm‘“nd d The irj'‘c ion should be given
With ib^ p^ c-* propp-d up the ons-t di/jurcss is a
mral to s op th" mj-ction and to Ia\ the p-ticnt fl-t
b^caus*- th s means i^^t a s^tisLe'o'v fall of blafjd p ^ u ••
b-s b-^-n o'" ain-'d a^d tb* full do * is and
m^v p ovosc too s*ae c a rcac cn Th* b-iam* brniu'*'
co^pou^ds <hoj d no be erven I ~^Jh in r-n-raf p _r*r*c
lb* r su ccssful ad'Tm s ration requ nrg co" d*^ 2 b * Inow
ledge a-d cxpc*’*^cc ^
50 Jan 6, 1951
ANV OUES'JIONS?
Vrr>*CAi
Intriplciirnl I* \.S
0 — //(It iiirri I’lciiral run iiniliianilu \hi t cUt (I'iJi}
Inn Ineil in ilm iniilnrni of rtttnun nr\ uiheniilos
If III nllh u/in/ rfuitis’’
A — Soliillonn t'f ji r.i iiliini'filiLyliv itij lu\c t ccn ii cil
LMciiNtcIt in llic Ircilmcnl of ml 'tiiilmn cmp,ct>in
I’ A S fi iitcn itiiripkiir ilh iimiiII) in Ilic fo in ( f n CIO
■lOltKion of (lie «(' liiim till 5(1 to *.0 ml l>'in micvicti
'\ccl,l> nccorilmj to III* ^cicnls of lli- ntc the icnilit
ire ^ irnhle nnJ dcpriul on the ilc tee of tlimcriHj of the
plciin inJ the (.liioninn of the Umoo the proc iir of t
hroiKliopIcii 'll fotiili ililioiji not m nt tot ne coin
indmlion ivill li tc i icnoiii ml cite cllcil on tf r
ircTimc It
To ohi in the hett rcMill« ill put iiuiti l-c ntpinlcd fion
the plciinl civin nni! tin ti nj m lOnn! out «ilh tinriinl
sniine I cforc the injection of the I’ A N inlntu n In cit-t
with <;c^ont!ir> mfcciion lint ilioiiM Ic ircTir 1 «iih p-n il
lin I cfo c ti'ini P \ S I o il ancilhc'i t lonlainni pm
aminol’-niou ncid thmiM not le ii -J tuih PAS at
ri rn iminol cn/n 1 . niul intmomuct P \ S
In tint coiinlit the noil fitoiitiMe rctiili' tine I 'cn
recorded In 1 Ci Diinptet ind M It I oj ■■ (/ onrer 19-!”
; f.7t Inhfrc’r 29 2If)
\ I) Proplij Inilt
() ~ II / ( I (ire thf lei! i ei. suet of leisii t /ropiitf to
Ilf an II senereni iliiei n ’
\ — \ condo n ttrcftillt put on md cmcfiilh icmtncJ
will nlniotl (.ctnmK ptetenl infection o' ll c partt cotcfvd
hilt not of coiit'c of the tiitronndint tl in
Ilinrotnh mvliirii of lie \ hole renml nei t ilh toip
md niter followed h) the ippik ition of cilomel cttim
(tonlainini n tiilplionatnid* o'- mcrciirj o\>k) miJ 1 "ill
prevent infection m the \it| nn|oritt of ckc if c irried
out mime Inlelt nfier ctp'tiire
Pcnicil'm nhlel fipOCKH) tini t) tmliowed within i few
holirt of etipoMire nre tud to pretent inftclion in t Inili
proportion of cites
Siilplndn'ine one or two ( r imnut t ihen it once follow e I
b> 1 timihr dote nett niornmt it hliK to pietcnt the
detclopmenl of (onorrlioei Init not of sjphlht
A few ciptiilet of lureoiiicin cich of 2'0 it t twni
lowed soon -iflcr c\poturc will pioh-il !> pretent infection
With either i onorrhoen or ttphili hiil few intctlnitions
with this mlihiolic lute >ct been reported
It will be clcir from the foretomi lint the sooner and
more thorontlil) proph>l-i\it it ipphid the Kreitcr will he
the clnncet of pretenimp the detclopmenl of infection
Amplicl imliiL nnd Ciirdhc Arrhtllinilii
Q — Is ainplulamlni likils lo linl In niiruiilttr fihnlla
non in a healiliV person or in a person n/io siiPert from
mitral stenosis of rlicnmaiic oriiin iinil has a histors of
St sera! hpiils of eniri<iiliir fihrlllalloii '
A — Amphct-iminc is unlikely to Ic ul lo 'iiiriciihr fibrilli
lion in 1 hc-ilth) person But on the whole it it wise not
lo use such drugs for pilients who lute i tendency lo
c-irdnc irrhythmiis md cert only not for one who siiflers
from milr-il stenosis nnd who Ins hid seterni bouts of
pnroxysmni nuricuhr fibrill ition
Lupus I ryllicmntosiis
Q — B''/inr ts kiionn of tin aetiology of lupus erythinnt
tosust M hat ts the trcatnuni of tin acute ihisernma/i il
and the chronic localized larielies respeciiicls ’
A — Chronic nnd acute lupus erytlicmnlosiis nre thought
by most 'authorities to be rclntcd nnd occnsionnily the one
IS seen to pnss into the other though more often the types
retain their identity throughout their course Their lelio
logy IS unknown but is nssoci itcd with i dislurbnnce of
MS tilir fiinctinn nnd sometimes lo the ndjiisiment of this
ti> elm itie conditions locil sepsis drug therap, and
sometimes other disorders nny net ns predisposing factors
I iiipiricnl trcitm-rt with gold injection is nl present ih-
iiii'l h'lp'ul iii'isiirc In lie ii inngemcnt of the eh oni
form of hipi s crylh'-iitilosi i
In 111'- SCI le typ- ndre uKOiticolropic hornone (A C T 11 )
nnd coiii one piudute drnii’ilic resi Its but lie d sease
rflii ns ns b ills ns eser on their wrthdrnwal Some ens'-
hise n >w b-en rep ttc 1 m whrh prolo-iged adminiitral o"
of the ' sul linrces has inn n! lin'd iinprovcmcnt In so-nt
cn'cs ihi 1 ip oscni'nl has Insicd for periods of mo'dis
iftcr III' cc sit on of ihcripy
Clirmilc Otitis ! nlrma
(} — A f,lrl I f 2 1 1 1 s t ^ I ^'i rn * 1 1 nirii o'lii? extern
for IS 1 o I r 7/ e (O' IttI ' I e i 1 1 r ser es of hi dr it
tie et e 1 < i r nn j ' hi p oied rex i! r to ortioJot
lie I net II / ( Ire n ter' i su
k It s mil I 1 ' \ ' ih iryi", i riehatn n cill 'r bs a rasi
lie ap, op'in'e (h> - I'uig dc errm"'(l I") n radie'lciri'l or
by tl " local nppli^a ion o' an a’ci hohe suhition or satn s’
lO itanng I'm it m \
t lc.lil hcailcdness In I Iderly Diabetic
<) — A hile'or I e ' 72 ul h i. o I’d dee ee of t't^' elei
iieliitiitioi ro'le' hs diet et p'l u of r ten ton of hel
lo le *resi it' eh 'tv tdter cn 1 1 to t I tl e I oh eh e ers
I irr Ir tier I le !sf i 7 h'l pen tij for It o or thee
/ '(( i lilt hos I preit ire It < ’> j/d ,* '! r tied He cht
supers ft"! 111,11 of ePi 't III h tl i e use of tin
lensalu'i i - 1 ii tl rre i s tree o 'i l
A It ' s pro’ nil- thni t'u< s,np.im is rcl. 'd to
irttsicn dis'url'-ince of tl - cc c’ t! circuh icn poMicti
Itrl) ns the presen c o' ipginn irdi-ntrs nrtcri 'c'cros s
It IS nt'sisable lo eosu e tint d 'lecitmn should be as
ncitls clforlless ns pisutlle ml ti' this end Iniuid pnraflir
si oiild 1“ p es-iilv: I to I cep 11 inl-'linal conicrts soft
If p 'ss hie the pnticnt should hreilf-is| 1 fore 1' Ins
dressed tnd nfter tic K'wels hasc Ken evacuated he
should letiirn to led for mim"rs On first wakir!.
he s’l iilJ like ) ir'ft; me) o' phcoobirbitone
Sitrllirjilon of Syringes
(J — tl hi intlseftit I ilsc I le tti I oil ct dl he resom
iiieiule I lot It hliitr to the liil ritit it of i i irlecltor ssrt tee '
II I at loieeilrnnon st mil I le leiess n to piirrai It e ll t
slerdllt of the ssti le’
A — It IS impos iblc to sieiihzc i ssriii,!' by this method
rsen rerrmcides m solution m w tier dr not penetrntc the
crevices nnd ill cheiiiici! mc'hods f sterilizing synnees
hnse been found inelTcclisc Obvn isls nrens not reached
hy in nt|Ucous solution would .’p, even more imcccs ihic
l(> 1 siscoiis oil I uhric ition nnd sierihziiion (hy drs bent
or ititocl ising) slioiild be sepinlc processes Tull insirus
lions md subsi mlinlion of the siitsincnis nude will be
fcrimd m rhe Sterilunlipu Use and Cere of VimicirfMcdi
c-il Kcscirch Council Wir Mcinorindum Ko I*- HM
SI ilioncry Oflice 1945)
Afl commimJcuMon* >>iih rcgtril to editorial btninc'^ AhoiiUJ be add c<tcu
tl Thf IDITOK Hmtisu Mri'K al Joit'su ll M \ Holai TaMMKTc
S qtiAur LoM'OS \V C I Ttirrnnsr I USTON .111 *^**^**'’?_
^nl <»e> 11 ejfrenf Lvnltn OI 1G!''I M APTlCll^ AND LCTIERS
forwTTilcd (or uUlealion nre im Icruood to I'c ofTcreJ to the British
\trticat Jtttnal ftlone nnlc^t the contrnr> be stated
Miihirs dc frne UMRINIS ihnild commiinl aie with the Publi hins
Mnmeer IIMA House Tft\lsiock Sotiarc \\ C 1 on tceeipt o( rn'ofs
Author* OAcrsrti sh nild Indicate on MSi (f reprints are required as
proofs are not s ni ahrmd
Mn C RTISI MFNTS sluMild be addressed to the Adveftiscracnt MantRcr
IJ M \ Hoic TcivIstxK Square London \N C I (hours 9 am to
pm) IrLieiuNc FUST ON '’111 IriroRAM^ BrlimeJaih
M ejrrenr Lmdon
MfMIURS SUI SCRII TIONS should be serft to the SI CRIT SR’V of the
A«ochtlon TiLrrtiosr LUMON -111 DiCQaAVis htedlsfcr,}
11 eslcfnl Loriil m
n MJV Scomsii Omcr 7 Driiimhciifih Gardens Tdlnbursh
LONDON SATURDAY IVNUARA 13 1951
A FURTHER STUD-i OF THE TEETH OE 5-YEAR-OLD CHILDREN IN
RESIDENTIAL HOMES AND DAY SCHOOLS
m
MAY ^tCLLA^n^
tso
nniN MciLANn^, md, rito
«illi lire A«Mnncc of JO JO\ MZR, nnd M \I!ION Mril\
It was brouj^ht home to one of us in 1929 when cxinnn
inp the tecih of some *' \eiroId children in London
Couni) Council schools that there was a grcal differ-
ence between the condition of their teeth and those of
children lising in orphanages in the Midlands Among
thcLCC pupils It this time there were onh 4 7S-j*'Mth
caries free or almost ciricsfrcc deciduous dentitions
whereas it was obsious at a glance that the number of
orphanage children with caries free teeth was much
higher In 1944 the chance arose of maling a limited
number of sastcmalic inspections of the teeth of children
Using under different conditions It ss as decided in the
first pi ICC to see whether ans changes had occurred in
the teeth of L C C pupils bctsscen 1929 and 1943 The
improsement was so great (the 4 7f; of 1929 had
increased to 24 29 in 1943) that similar inspections sscrc
made in 1945, 1947 and 1949 (Mcllanbs andCoiimouIos
1944 I94f> Mcllanbs and Mcllanbs 19-,'! 1950)
It was not until 1945 that an opportunits arose of
seeing sshether there was an> real connexion bctsscen
Using conditions and dental health in orphanage and
LCC children Concsirrcntls a similar inquirj ssas
made among pupils Tiicnding prmte (fccp^iing) day
schools lilc the I CC children thej Used ssath their
ossn families Mcjnsshilc sarious ssorl ers had obsersed
a tcndcnc> for children brought up in orphanages to
suffer little from canes sshilc others including Collett
(l‘)tS) and Sielmitr (I9i9) in Norw is and \ndcrson
el a! (19’4I in Toronto had published a fess figures
relating to mixed age groups indicating that there ssas
less canes among such children than among the general
population The threefold surscs of 1945 (Coumoulos
and Mcllanbs 1947) shossed that children Using n
homes had the ssorst dental s'nictu c suggesting poo
cikilsing diets during tooth dcsclopment and set had
the l-ast ct ICS — less than the children of comparatiscls
Well to-do families and much less than the LCC group
It sssu'd base b^cn instructisc bad ssc bs-cn ab’c to
paralM esers si-xes in LCC schools ssith s milar
insp'vtion an on- residen lal homes and p is i e school
shi'd cn bit Ih s w„s nst passible Ear's in 19'0
howese t’ e tsso g oi ps n question we c 'cirsestma cd
T! IS se-nied c p-^ialls u j sue tb- p es*rt po! ex
o' bsirdi"'o • .-J sdisp on is 'cmosj-- r--si's a’l
' S sS ds ' o- 1 o— ir’S
In s pap- v.-acus"" h" tc"a " t-o-’- o" 'r«i
dr- lbs-- to esse res d — lal --.-s- rs and s x-a-Is
admi- s e cd * s t’ - S - e o ‘■s so -'.-s s-as j, j.
s s s s ssc ea' -d -' It 1 a-s 7b-s - a e r" - i-ej
for children deprised of a normal home life for i sarisis
of reisons su-h as the death prolontcd illness or p ison
sentence of one or both pircnts illcgilimac> or lack
of suitable housing f icililics Pormcrlv such children
sscrc accommoditcd in orphanages or insiitutinns of
sarious tspes including ssorkhouscs
Oinical Material nnd Mcliiods
So far as possible the same homes and schools sscrc
included in the 1950 sursej as prcsiously but others
from near bs districts sscrc added to increase the size
of the sample In all 45 homes fmiinls situated in
I ondon and the surrounding countr> ssith a few m the
Midlands) and 32 prisatc ind jndependent schools ()n
I ondon and adjacent counties) sscrc sisilcd the total
numbers of children dcntalls inspected being 542 in the
former and 560 in the laficr group In 1950 as in 1945
the aserage age of both groups of children ss is jpproxi
matcis 51 scars
Tlic standards adopted for hspoplasu and carles m
the clinical examination and the methods used in cal
culating the results sscrc the same is those tmplojcd
on mans presious occasions The degree of h>pop'asia
ssas estimated ssith a right angled probe and the
rougher the labio buccal surfaces the greater the degree
of M hspop'isia for diagnosing canes an illuminated
mirror and sharp rat tailed denial explorer of standard
size sscrc used The teeth were neither dri-d nor
X rased since although these aids to detection ssoild
hasc rcsu'tcd in more canes b-ing sc-n the fmdinjS
ssould not base been comparable ssith tho - of p-st
sursexs morcoscr the diagnosis of ll c p gs-n-c «nd
extent of cincs bs ans kno sn m-ihod o'tei come- in for
ciiticum Tor this isp. of ssor) the irnpo tint thing is
to h-sc arreem-nt on the ' andards to be dop cJ fo!
losed bs ad' ercrcc to th-'c s andards on trie part of
the inscstiga o s ssho must wo i m close cod bo ation
Thcm-lhoJ of p c eating lb- firJ ngs csp-.nlls those
rclatm- to ea i-s is also op-n to c ti-i'-n V. c base
con dered the irgu-ncr's for -rd -g-'n j f,ur 'em
a-d t*-- sch-r--s adogtc! b> 'ime o’b- *o 1 ers bat
fp sarious rc_son ac p e'er to re a n cu oan 'Iml
den -I rese- eh ssolcrs co-cc-' -Ic r-- n's on t* -
i-c 'cnee of di'eas; m-' Ji- c idi.- - o' p t'-ca in
cco J t*-- d— tal s _ s of a- g -n g o p o' 'b-
piag tion Tl's o'ten ico c t' c s rt i - o' t'"-
icc h api • f OTi I*-- g o's- 'o ns o' d-f-cl and d'
b-a-i'g o- t*’- I _b ' s to o le- Vc bnac e- f-- 1
s’ron- iSst b's ’ sS-oj 1 t- co- 2- ci a-d t- t i-
_-co d.—e with ‘"e p c.ep s o' p esc- c —-dr -r |-
c“pha' s '’ou J oe c- t'"- w- <_ c f-d --d ea c"-
4697
52 J\N 1^1951 III 111 O! 5 'll AK 01 D (Jill DKI \
frjTin
*>tir ^*L )oc> ui
fat Ictlh rillitr III in nicrcli on the incnlencc of dcfitt
or di<;t isL In iisint Hit rcMil|<; of the Mir\c\\ there
fort \Nt mintion hrst the more ideil >.tiic whith il
K liop d mote tliildan will u'liniiteh HI iin
In iv^vssmi the iiiiihlt of llic Kelli dniMon w is nndt
into those iiliich wtrt cstcrnillj smooth (no hspoplisnl
ind those Kith \ ii\in[ dej acs ol r ' i, h i s of lia I ih d
or biitcil stirficts Mhspnplisii (Kinp l‘>:Oi v\ is
grided M 1I\, to M lU, utoidiiie to the incti isini
scscriis of the defcvts uhilc teeth Kith ceriini kcII
dehnid tips of siirficc irret ill itits vttc is helots
chssilicd sspii ittls IS i ross or tcslhoo'. hspoplisii
Ihe niinihtrs of lesth in the sirioiis citeponr of h/po
plisii ire tspres sd in tlie t ihles ts p-tsmi o ' of the
toll) iuinibi.r of teeth c\ imiiicd An\ teeth kIiicIi 'sere
so cirioii or hid siish heiss deposits of tirtir tint the
siirficc structure toiild not he j iii ed sssre omitted f'o ii
this tl issilit. ition ind tlius from the I ihles dcihiu s ith
‘triictiirs Ills iseriee sstsiit of sii f ice tevtiia cKfest
ol the M Ivpe 1 rep e cut d In the isersi hspoplisn
fi tits (A H I ) this in conjunction Kith the p ten
lijss of lupoplislit Icsih IS Kc h hese u efid m
issessiru tla improscmcnt or othttssi c in Ih- dcitd
stnicliirc of Misses nc simp’c o' chihlreti -for
cMinple 5\ti'’o'd I CC pupils es iniincd hetKceii
ion ind 191')
Cirits IS LSprts ed both is mtidents ind n cslent for
cich tsp' of tooth ind for the sum of ill tsp.s m
cich group of children Ihe incidence of dec is In
itstif Khsihcr given is i psrccnti'e or iis the D I
(dtci)td rnis'-inj mil filkd) In me i m lie rniste idinr
since i group of individiiils with snnil civilies wonld
ipp'ir in the tih'e to hive the sitnc imniint of tines
IS 1 iroup in whieli the civitit vvert hree lot this
rt ison tilt estent of cities m cich dctivcd tooth is
dcscrib''d is heinj of tr>tlt I 2 or 1 icto dm, to tic
cstim ittd si/c of the civitj in rclilion to iht sire Oi the
tooth Iht ivcric. ciries fij urc (A Cl ' hie the
Alir IS some Inttion of 1 ind me isu s th- csti
mittd ivcngc estent of cants in the ictlh In our
opinion the idv ml ire of this method ns ii iinst those
involving tooth iiirf ices is its rehlivc smiplitilv ilso
the results so expressed nrc compirihlc with those
prtviouslj given m this scries of aports mil thos- pub
Iislicd by others using the s imc mtlliod (Devet ill 19)6
Divics 1939 King 1910 Coiimoiiloi 1916 Stones
cr al 1949)
In ill the surveys mide since 1913 it Ins lacn possible
to cilcii! itt from the pubhshtd lij iircs the 19 M 1'
vilues for uislmte the pcrccntirt of eirious teeth
IS expressed in T iblt IV and in c irhcr p ip^rs is cqui
viicnt to the D M r per 100 deciduous teeth vvhtlt Ih
loiil number of cirious Ittlh divided In tht luiinbir
of children ind then multiplied b, 100 gives Iht 19 M T
per 100 children Since the deciduous incisors arc in
process of being hed between the iges of 5 ind 6 years
the missing ones ire considered in ill our surveys to
have been lost natiin'ly ind ire therefort omitted from
the tables On the other h ind inv ibstnt c mines and
molars would ilmost tcrtiinly hive been cxtricled for
canes al this period they ire therefore included m the
canes totals (grade C3) It will be seen from Table I
that the mijoiity of missing incisors m this age group
arc lower centrals m which there is very seldom any
decay so that the total number of dccivtd teeth which
might have been present m those counted as shed
must be small It is obviously more difficult to inalyse
caries figures for children of mixed age groups espe
I A*'M I — J ffcrnhi ft tij Fffth I /r rut rt Time of httf tip
1
1 ( li i* j
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rrMi! If
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tidly iho " b tv ecu 7 iiid 1 2 veu hccauvc the times
of c iipimn and shedding vary wnlclv for the
3 veito'd tnildicn the I ivl is rclitivcly simp'r From
I able I It IV iliu seen tint nearly •'ll Ih- tctlli arc still
m Situ Kith the cvtcption of the lower central incisors
V hith ate norm ill shed re' tivclv cirl
Res lilts
I ibl- II shows the p tcniiges of chi'drcn in the
IV iv proiipt who were tines free and those who were
icirlv so 101 ether wuli the mimbe s of D M I teeth
p r 100 children
Tv I II -n 'tfr fi I t r If A!" I S > a f dr D Vf f
I . ’ ri /r /( 1 (/ ( r Af ' 1 Ih ft II II ) -nl
/ ffi
Sr/' >
1 rrs
fit »*» j
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c*tci ;
(ti fr"
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4
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1 4
Mllioiiih the Inures for tines free children ire given
Irre to conlorm with the reports of all the earlier sur
vevs of the cries it his ihroual out been rvili/ed thil
where the dilfcrcntis btlwccn the vinous groups under
review irt not spivlitiilir a betttr picture is giincd bv
tonsidennp teeth r ithcr thin dentitions Ihus some
10 more priv itv school thiUlnn had dental dccav in
1950 yet the told p-rccnt it c of tines free /< tJi (Co) was
ittii illy grciltr than in 1945 In other words the
disc ISC w IS port vvidtsp cid at the lime of the later
survey hi t vv is of 1 milder form (sec I iblcs II and IV)
Ihe findings rtliting to Iht teeth as opposed to th-
whole dentitions of the children irt iivtn m Tables III
to VI In tonsidcring them, a comparison will first be
inidc belwetn Ilit 1950 and the 1915 results for each
of lilt two groups of children sep irately Then the
rtsulls for tht rtsideiitiil homes ind the private school
groups will be tompircd I’issing reftrcnecs to the
findings mice schools in 1949 ind 1945 will also be
mailt although tht interval between cxaminat on was
SIX months less for Ihcm than for the other groups
Surface Slructurc of (he Teeth
RcsKhnttnl Homes iii 19'iO amt 1945 — It will be seen
from Table III (toliimn 4) tint 42 Cf, of all the teeth
were perfect or nearlv pci feet in structure — that is
hypoplasia free — m 1950 is compared with 32 3% m
1945 This improvement was found in all types except
the uiiper first molars, which remained the same as
before and tht upper second mohrs where the
Jan 13 195!
U nil 01 5 "VCXH OI O CHiI DIU N
ptfccnl ire ciccrca'-i.d Ml is rcTlirci' Int tirlirdcpo its
found on i proparlion of i ppc' niohrs cspcc iii
second molars ma> m isi tin. ‘^ti-l surfa^^ tcsturc
thus mailing it dilhcuit to jss.'ss th. ructurs and th-re
fo s an\ change Pus applus to all our su css ) The <.
ssas scr\ little M hspopi sn of 'I - most scscre grade
(M Us,) in ans l\p; of tooth in I'Pfl less tinn P of
ill the teeth examined fillin" into this categorx s
compared ssiih the shrhtK hi li'-i fi urc of 1 7'' m lOd*!
I he Alir had dccrc sed fo esc \ Isp- of tooth
except apparsntls the iipp'-r s'-'oad molars the told
basing fallen from 093 to 076 Gross hjpop'asii
though rclauscis loss in huh cues was losscr in
l‘P1 th n p esn 1 I 17 of all te h •’s c 'ipircd
with 4 b in l'>..s b i"_ a ’sviss' Is this f s "i of
dc'^ect
f'r i, € S / ir t !“ I t ’ ‘ ^ — \ 1 s ig thes"
children d e dentil stn cti c s is ib u t a Is lu- nu
n lO'O as in the c rlie' sms s Ihc s sss l ^3 ’ of
tiL toial tscth f -s Iron) hspaptis a as soupar d s itl
“stO p ss ousis n d 'l hi colum 1 4t Soi e s ch is
the iipp - in..i o s ind can re h ass d imp oscit cn> a
the fisc seir p-rii’d ishi'e o he s n ata! is the n o ir
ssc c not a good as fomi'rls
\s in the cue of the is ids i lal honvs sers fes'
tecti had rsalls seserc siruclurd d'-‘'s‘-ts I'l Hs ' ll s
Tsri r III -Conir nn nf 1 oo I ^ rncturr tn Krsiilr tit 1 Ht r\ iR U t rr ^ Prttrtf Sc}
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ACI
54 Jas 13. 1951
H LIII 01 5'iL\R 01 n CHIIDRI N
Miirfii Jon/txAi.
proportion btinp 0 1 of all the icctli c\ imintil tom
pirctl With I 2 j in 1945 Hit onl) ivelh comint within
this tridc 111 the more recent sur\c> wert tht niohts
There w is vcr> hlllc sariition in the All! for the
ihlfcrent tjpes 'itui the fieurcs for ill ivpes to; tilicr wen.
thcsime Gross h>popl isi 1 w IS ipin \et> iintommon
in tithtr jt ir the tiinl imoimt in 1950 hcini (1 1' of till
tcLtli cs-imiiictl--l less tlnh in 1955
Coniptiri\oii <)/ //i«ii( r aiul VmtUt Si/iKilr—lt still
be sun from I ible III tint thcchiUlrcn in Ih’' tisiilcntnl
homes in 1950 still fml worse dent il striKtorc th nt iho c
in the pris iie jthools 5}. 0'^ of all teeth as compared
ssith 17 1", shossmt' sonic depice of hspophsn (A 11 1
0 76 IS ipitnst 0 59) Since, hossescr in the former
group thirc Ind been in impiosemenl dntmt the pist
fisc scars—ilnt is the pcrtcnlipc of htpop’istic teeth
hid fillcn from 67 7 to 'SO i I4‘ reduction stliercts
m the litter troop there hut b-cn none the dispstitt
t\ is kss
ICC Sfliiuilt — \tnoni the I C C group examined
in 19 59, ilthoiiph the peiccntafe of lispop! isiie teeth
had mere ised soniesth It since 19 '5 b*ine 6Mp iiscom
pared with 62 0 the A II I w is much the same 0 5x
compircd with 0 91
As rcpards dent il structure therefore these ohstrsn
ttons indic ilc i jcncral improscnicnt an ori) the tesidcn
tial homes pnpu! ition since 19*5 but hlilc chain c imon
prt\ lie schoo's or the 1 C C i roup I he pris ilc school
children hid on each occision the best formed teeth
svhilt the positions of the other two ( roups were resersed
nt the time of the second insp-ction the rcMdcntial
homes proiip his ini heller t deified teeth linn the 1 CC
group though not re ichinp the si ind ird of the pris itc
school children
Carles of the 1 telli
In iiiliniiiil //on ei in 1‘J^O and /'-'/S — labk IV
(column I) shows thit in spite of 11 c f ict that a larpe
pcrciiiiitc of the teeth were cants free in 1945, there
w IS in impioscmcnt darinp the live jears hetveen in
sj'cclions the tcspsclisc hi tires b'ln; K9 5 and 92J? ^
of the lo'd mimlvr ex mimed This improicmcnt was
icflrcicd m each i)pc of tomb but esp-eiilU in the
molars, md in pirliciilar in the tipp-r moLrs With
re, atd to discisc incidence there were ser> few carious
teeth in I’l'-s'' rcsidcnii i! home children m 1950 ,onl)
7 2 of the total number h*inp alfcctn! a? compared
with the p csioiis II) lire of 10 5 which was in mH)
CISC scr> low In pissinp it mis Ic noted how small
ss IS the p opafiio'i of carious teeth praded C remem
berm tint this catcror> inch des exir iclions The extent
of cities IS exp cs‘ed h/ the *5 C 1 fell in 1950 fo
cvets indindiiil tape of tooth the hpiirc fo’’ all tjpes
(oi ether bcin- P 12 as compared with 0 19 m 194'
/•/mite Vi ltni>h ri! /9'0 1 1 d /9.‘5 — The p is at school
children showed a slijht improsenent m the fnejear
inters if I he total percent ige of canes free teeth rose
from 65 s I,, s 7 a and rich isp* with ih- exception of
the towe' ic ond molars shoscil imp osement The
pc cciitipes of carious tcc'h at the l so inspections were
thus It2 in 19:5 ntul |2 7 m I9<0 Ihc \cr fo
cich t>pe of (oath m 1950 was (he simc as or lone
thin before so (bit the totil \CI showed a slight
rcdifction (0 2S to 0 22)
f ontp rison of Hornet nt I I’nti'e Sdodt — The
(initcs jisen m I ible 1\ mficitc that ns m 194'
the teeth of the residcntid home eh Mren ixnmmed in
1950 still hid less discise linn those of the pris ate
Icmi \ It n !i I te I’f Ciinet in Terili tilth i On 'n of Stitnlii'e
Olhiiuti I (SlCa-n 1 I 1" 1 'AO (tl Mlaiivs
(t) Cfailc «>f
Sfn/ tufc
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Irsul
1
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t MMf)
. '7
/4
1 "1
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i>7
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{* 9J
( a ff
44 I
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i 1
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333
Us
34
If 1
i>h 1
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K 1
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t’S 11
___
...
_
— -w— .
—
- —
—
“ “
o(r —rof iomc } rjd
t of «tru
(urc (he nu/fib /•» uf (cefh * ere tclit vtf/y muU
ihcr
rv niAi-
1 .nc 1 1
1 n Ih w
t hT>rJ*u) M*ni
CAT C
»r*3 vf
ihcrcrorc gi^tn In bnekeu
Tmui VI 1 1 ( 1(11 of Canetm Teeth ntth I n/im;, Crtnltt of ifriHliire
{3} lotm f4 I i4JCanliiCT j (5> MtiUfs
{() VtlThTct
{/) Grade of
Struc-turc
i
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r
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1 tTMi/n d
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i /*()
1950
l*)4'
*7'0 '
[ f/45
P730 1
1 lias
l‘>50
11
1 >'0
|9!5
1950
Good (Ify )
K if
i 1 ■’<'/
2fn3
1 i> t i
UlK I
1 'lb
1 <
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1 *0
n4
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i 9
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0 O'* j
' 1 «7I
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0 0-
004
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/{ /{
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' r 3«»
KH j
0 04
<»<»
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0 u
0 f j
■•477
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0 07
0/3
(M Hy )
PS
523
81!
i IMS
0 H 1
1 3 50
457
M \\
tMl?
\ no
55
0 Rj
0 30 1
;* fb3
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1 0-7
0 2'
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1 0 n
O 3
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; t U'7
1 50< (
0 M
0 '0
) \ 315
J 775
i 04>
0 19
Pb
145/
83
1 0
fit nj 1
^ Jr
W 1
' f" /'!
h wf j
' rr >
UUi 1
/ //
0 n '
9 854
) JSS
i 00
0 57
Very dcfcciivc
H )r
13
a i
1 m )|
[0 -*5} 1
i 3
1
1 /(HKi;
17 1
!J O')!
llUll „ 107
M
1 0!
[oail
Pb i
8
0 1
;1‘ <t}
0 oo 1
"1
(OtHij
GOO j
77
H f
!’ laj
ill 11) '1 S7
14
1.07)
111 !ni
Gross (G Hy)
R H
80
V, 1
I'UI)
10 ni 1
1 24
4 !
fOlHU
{ » wi .
» 77
~ 1
0
0 IK '
301
0 47
0 IB
>' 1
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! 7 50} j
i 12
M
{0<K)|
{«<K»| {
4^
5 1
(Ob6|
tl -0) (
! itb
10 7<9
fnas)
(her^ore gjviTn iifhrackcu^* of'sfnicture tlic numb rs uf (ttdt were rtlitiv ly mhiM Ihc VC* biud >n tlic^c probabty (n\r hdtc siiknifii-Tncc «nt3 nre
13 1951
rr LTfi or «: m:\r oi d cnii i)Rr\
school cfiiMrcn 72'* in the fo rTT frnup cc'npifcj
Viilh 12 7 4 in llic liner beinr c i lom Thom h n i o*h
caici there had been in imp oicmL"! in It c fise \cir'
Ihii Was proporlionalcli p cite in llic former (i drop
from 10 5'' to 7^"j of ciriotK t'clh— n reduction of
720% — compared with n drop from 1-5 2 to 127
in the priaalc achool proup-a redu^tioi of 10 ‘i ) «o
th It the pap between the proup h d widened diphtly
ICC VcAoo/r — tn conlrot to (tie ^Irht in p oaement
in the aboae mentioned pioiips tlic I9-9 aiiraca o'
I CC achool-childrcn shoaed no inproacment in the
canes position as compared aaiih lOaS 'TTi'- proparliona
of carious teeth in the two jears aacre 20 5 in 19-55
and 2(i7% in 19-59 aahilc the correapondinp aaerare
canes figures were 0 55 and 0 '4
So far as canes is concerned then the children of
the residential homes h’d feaac diseased teeth than those
of the priaate schools and mana fcaaer than those of
the Lee schools at hoIJi inap-clions It niiisi be
cmp'iasired again that the canes incidence ind extent
bolli in residential homes and in priaate schoa's ire so
low that improacmenis are incaiiibl) small
Relation lictaaecn Stnictnre of Teeth nnd tlieir
Siisceptiliilila to Canes In 19'n
It aaas found in the late t suraea is in 1915 and all
Ollier siir\c>s of this scries that aailhin each of the
groups of children the better formed teeth -that is
those asiih no hapop'isia— aacre less h ibic to c tries than
the M hipoplasiic ones and lint the more seacrc the
defect the greater the h bdit) to the disease (see T ah’cs V
and VI) This is Inic for indisidiiil Ispes (inciso s
canines and mo'ars) ••s asell as for all teeth lalcn
together To demonstrate this paint figures are giacn
for three grades of structure in Table VII
Tirj- MI
h O >**-
ffcrlC t
'ft tf C •
1 fill
rs 1
\ n
O'*' III 1
1
^ 1
1 K •
1 s
a t it K 1 »T (V H )
1 ?
> «
too
Orlcct T ii »» 1
f7 T
<?<»
' ■>
-T#
T? f %rrT " i-tu ni— Vr» oT Jl »f*t4i la t*»T i t t i t» irt-**
In all cases it asdl Se se~a that fo* a g sen g'lde c'
St 11 tore I* -re aaas less ca les ar-rn- t'lc chi'dren
frsa-n rrsde-t al homes I’l n r"ong 1' me in I'lc psiajlc
s^hca’s I III ' s rcfcicnce to th s ps -i is made in the
d a ..ssnn
r - Ss
7 s
ni n's'-r of Idlin-s brn- p c —I It r i 1 b- j - cd
out haaeie I'lit s'l-' th oas o' If r c r i i a
caaiiies in the resid-ntnl 1 amca were ac a sn-ial’ i( ^
gndine' aah 'c fc acr ( " lo't'-ptaile s' i o’ caa mrs
aacre g r idcj as C,
St iinirg of the Surface 1 ranict
The sup- Ills aim"| o' dcs Ji nu tee h as'i h is
o'icn cisntincd to th- nnrii a) m ir in an I mo' ( st
has been camn enict! on ba sc - al asmle In pisi
surae>s a no e w x made of ihis con hlion an 1 il as as
found that those children with d 'lOitc b' o I man
stiintne on fcas o naana ! cth hid less a in- thin
children aailh n me or children v ho - l-clh sho ml a cli
mte green a ainin, In this most recen* si raca tie e
aaaa aert little diflcrrnce 1 clwrcn the canes so -( liLihry
Tami 1\-
•-Ir t 1
I/-/ lyf Ct
in in Pr h
~ r»5
1 •* '
s
of Teeth
! 1
1
1 S.t
r'Ca- r- ■
i
r*
1
. 1
A 1
I
1
j IWS
17 JT
1 1
j
1 *
1 3
V it*H ’
n )t j
! I'v 11 f
T "^1 1 1 )
'll*
' ’ I
r 1
(' It
< J
I
rs 1
< 1 ' )
» A « ml • >
1 )
1 O j
{ *
11 > V 1
p It 1
1 I'Ti \\-\ A
1 l-lisu ll
< n
A t i
r 11
OO**
tr -.-i 1
t a 1
VS i
j u r
» • (4 » » 1
1 *
ira 1
1
; 001
< n
Oorn I
n II 1
3 r) '
) •) 1’ M
1 ''I
tl 4
( }>
f '
s, , j
rs 1
! M ( 1 T
1 < ( s' ||
i *
1» 1
' r <
n
of mouths
with b'sel
■’fi f bro in
si tin
'tnii
llin e
IS 1(1
none (Table I\) but in this conncaion it mu t I'
icmcmbcred I'lat there is acr, Int'c ciiics an wl -re
Mouths aaiih green stun app-ar more sii ip'ib'e fill
the numbers of chi'dicn With this stain ircsiill Irdcter
mtnatc a-ariclics of co’ou acre omitted from th" c deu
lations An inte rung pamt w--s t'le l3r,c propnitmn
of rcsidentiil home chi'dren— almii! 5a at ci-h in p-c
tun— aaho s'losed bio sn or hbel si ms is conpared
with less than 7 csf p laetc s.hoal chi'Jicn
Vimt of the Cariona rroersa
The'e w’s an appirc-'t d-e e_'c in a c-st-d c~riri
amnn" Imth g oup can pared with 19 5 In, |i,n
have b-en di e parlii ro I* e p tmilfjrra n ei /m -a
lion \rrt
t 1 ^ a p adinl p o c v
-an J i»
js nn! al vavt
c to Tp
Cc n a Ap* i*”}
r 1 I"
1 r in jj*) It
fro ) \c r
to VC r Th** d
ir*n t VO
fioiip on
t*'c oih-T li 1 ' I 1 re 1
- c
h C" l** f
re* I
rr 1 c
t<-. h
Win arre* c 1
enn-A J ^ ^
0 ^ •‘’I rlic re i
C rjo
V '•eh cr>*n
r cj ' 'i
o*'’ 2 n t' - p js 1
r 0 p So
r > >• c'o c t' “-c '
' " r*
’ n 1“ * >- »c
ffci C
to t* p CC
c-v n t
i - ic <5"* 'J
J
n
56 ]\s 13 1951
IIZLTH Of t YCAR OLD Cffll DUPN
pjrrmi
*!i£>icjil io ^ rMt
cnrics (from 10 5'’^ to 7 I", c inous teeth) m cpitc of
the fact tint at the time of the earlier >;urac> the total
incidence and cvlent of the disease were already \er>
low The prisate sehooh proup on the other lianil,
winch had compiritivelj pood tooth structure in l9tS,
showed no improvement while the decreise in canes
in 1950 was \er\ small (I J 2'' , of the teeth were carious
in 1045 and 12 7'X 1111050) I hus the number of cirioiis
teeth found in homes ehildrcn was rceluced by neirly
one third that in private schools by oiilv one tenth
Whether the results (ivcn in this report arc merely
periodic fluetu itions cinnoi be st iied No examinations
of these two proiips were mule in 1947 which vv 1 $ the
peilv vear for canes free teeth in 1 C C sehool children
It IS possible althourh iinlil ely in view of the already
small incidcnee of the disease tint the findinrs miphi
have been still belter then
W’hat are the reasons for these differences 7 A com
pirison between the two surveys docs not suppest that
the rcsluction in decay is due to iny v-ariaimn in the
siigir content of the diets or to the amount of dental
treatment given The strict ralionin" of sweets and sugar
during the war ensured little dilTcrcncc in this respect
Ihroiichout the post eruptive period for the two y roups
examined in 1945 and those inspected in 1950 would
have had if anything, more su"ar and sweets in their
diet Again there was more treitment m both the
groups seen in 1950 than in 1945 but for both years
the percentage of carious teeth treated was much greater
in private school children than it was in the homes
children
There miv be mans contributorv factors but in dis
cussing the differences between the two groups examined
in 1945 It was suggested on the basis of experimental
and clinical investigations previously mule (Mclianbv,
1923 1934) that the calcifvinp properties of the respec-
tive diets It different periods both pre eruptive and
post eruptive arc an important lev to the situation
It was pointed out thit as 1 whole the relatively well to
do mothers were more libely (from financial and other
consider itions) to follow medical advice then becoming
commoner, to take plenty of mill and some source
of vitamin D during pregnancy and lactation than were
the poorer mothers of the children who later entered
the homes
It also seemed likclv that the mothers in better cir
cumstanecs would continue to give their children such
foods in the months immediately after weaning Diir
ing both of these periods the deciduous dentition would
be developing and erupting In the post eruptive stage,
however, there would often be a change in the respec-
tive positions of the children from this point of view
Dietary discipline would tend to be rcl ixcd in the ease
of children living in their own homes especially where
likes and dislikes of such things as eggs milk and cod
liver oil were concerned In the communal life of the
residential homes on the other hand, fads and faneics
would be much less in evidence and regular meals of
high nutritional and calcifying quality including an
ample allowance of milk and a daily dose of cod liver
oil, were the routine, as was ascertained in the course
of the survey
Thus It seemed probable that the post eruptive diet
of the relatively well to do child might not be as good
for the teeth as the pre eruptive diet whereas the later
diet of the residential homes child would in all prob
ability be much better than that given during the period
of tooth development in this way the resistance to
canes of the teeth of the private schools group would
tend to be wealcncd, and that of the homes group
strengthened
In general these same relative conditions would in
our opinion be Id ely to obt iin in respect of the children
ex imincd in 1950 but where is the p'^c eruptive and
post eruptive diets of the priv itc school children had
probably remained on mu-h the simc level in the interim
(thus resulting in a rather similar dentil condition) there
had been certain important modifit Uions especially m
the pre eruptive period in the diet irv of the boni's
children The uaccr •’in qudity of diets talen bv cxp*c
lant and nursing mothers and weaned infants in 193S-41
(alTrcime the structure of the teeth of children seen in
1915) had given place to the rationing of impartant
foods plus a svstcin of specij) fool pmanlics for these
viilncrihlc groups bv 1943-6 (when the teeth of the
cliildren examined in the liter survey wee developing
and erupting) This prioritv scli-mc should have been
of especial benefit to ll c pao-er niOtbcrs the section
of the population from which the majo ity of res denlial
homes children are derived Th-sc priorities were avail
able on ration books and would in many cases be talen
as a matter of rotiimc cspccullv as the milk could be
obtained at a rcvli^cj p ice or cvia free and the cod
liscr oil and vitamin tablets were issued free to all
In addition more was heme done than formerly
through nnternitv md child wclfirc services to dis
scminatc knowicdjc of belter ntiinlion Some of the
children entered the homes at the age of a few 'seeks
or months and in these cases there wo iW be tim. for the
excellent infrnt and wcaninc diets given there to exert
their etlcct on cdeificition, esp ciallv of the deciduous
molars In such homes feeding had become even belter
than in the early w ir period owing to stricter pi inning
and supervision thus increasing if anv thing the favour
able post-eruptive infiucnccs of such diets
TTic vvorl of Sclnotr (1939) and Collett (1935) and a
small invcsiipalion by Kmc (1946) suegested that the
earlier in life the children were admitted to the orphan
ages and the longer the period of residence the less the
incidence of dccav Tlicrc was evidence of this natiuc
in the data obtained in the 1945 survev though it was
not published the results obtained in 1950 arc now
being anilvscd from this point of sicw
The improved dental structure observed in the rcsi
dcnlia! home children in 1950 can therefore largclv be
attributed to the belter nutritional status m the period
of early tooth development as compared with the similar
period for the 1945 group This would of itself tend to
result in a reduced canes incidence but in regard also
to the post eruptive diet these children leaeime a com
miinal life would appear to benefit greatlv Not onlv
are tlic diets in residential nurseries and homes well
pliinncd, but under the British rationing scheme there is
and has been since 1942 (Ministry of Food 1947), actu
ally more of the important foods available per child
in these homes than can be obtained for children living
with their fiimilics Moreover m the latter ease any
special allocation for the children may be all too often
pooled with the food for the rest of the household
Furthermore these children have far more say than
those in the homes in regard to what tliev will or will
not cat, and in many instances thev arc able to spoil
their appetite by eating food of low nutritional value
between meals
In our opinion, few families in Britain whatever their
economic status provide for their children diets which
Jan 13, 1951
11 Cl H OF 5 YEAR OLD CHILDREN
Bamsu
Medical Journal
57
are as good in their c ilcif\ ing propcrlic- as those scraed
m children s residential homes to da> and in few is the
intake of cod h\cr oil and c\cn nnlk lit clj to be nearly
so rcgiil vr or so long maintained It scenis to us there
fore ihtl the csccHcnt diet given in these homes is
responsible for their low cirics me denec The rcdiic
tion noted since the previous survev live vears ago is no
doubt parliaJlj the result of improvement in dental struc-
ture but It ma) have been enh meed bv the even better
diets provided for these children in recent years
It IS a challenging thought ihil on the whole, children
brought up in orphanages ind other public institutions
have a better chance of remaining free from canes
(at least up to the ace of 5 vcirs) than children of the
same ige brought up in pnvatc families
Siimniar)
The new resulls given in ilns r'prr arc compiled from the
individual denial charts of a viirvc> in I9'0 of 547 children
aged S \cirs living in homes (orphanages and institutions)
and AfO children of the same igc attending independent and
private da) schools mainl) in London and surrounding
counties
T7iesc two gronpv of children are compared wilh similar
groups esammed m 19-5 md with each other as regards
both dental structure ( leeordinp to the standards originatt)
set up b) Mi) Mcllanb)) and ciries incidence and extent
Reference is also made lo survc)S among LCC school
children in 1945 and 1949
Among the children m the homes (ooih structure was
found lo have improved since 1945 there now being 42 0%
of the Iccih free from both gross md M h)poplasia as
compared vviih 42 3 « previously Concurrcnily there was
also a rcdoclion m canes incidence from 10 5% to 7 2%
The private selioot group showed much the same average
structure in I9so as before svliilc the cirics incidence had
declined onl) si ghll) 12 7% of all teeth being carious as
compared imli 14 2 o previously
The avenge dental striiciurc of the residential home
croup slill lagged bctiind that of the private school children,
but Ihc dilTcrcnce between the two groups was not as great
as before
In spile of worse denial structure the children in the
rcsidcniial homes had a lower canes incidence and extent
The relationship bclvvccn dental siruclurc and canes in
both groups in 1945 and 1950 was such ihit llie greater the
degree of M hypoplisia the greater was the liability of the
teeth to canes hut for each gndc of structure the residential
home children had less dcciy than the others Tins relation
bclvvccn structure of the teeth and liability to decay has
been ob erved in all similar surveys where the same standards
have been adopted
In cich group of children there was an increase in the
amount of dental treatment both fillings and extractions
but pirticularly Ihc former At cich inspection the pcrccn
lagc of filled teeth among the private school group greatly
exceeded Hi it among the residential home children
Approximately 33% of Ihc children from residential
homes showed black or brown staining on their teeth in both
years as compared with only 6 7% and 4 8% in the two
groups of the private school children
Suggestions arc made to account for the differences found
in both structure and canes incidence between residential
homes and private schools and for the change occurring
between 1945 and 1950
We would like lo pul on record our grateful thanks to the
many people who have so generously assisted us and without
whose help this survey would not have been possible Porlicularly
we acknowledge our indebtedness lo the medical officers and
governing bodies for permission lo examine Ihc 5 year olds In
children s homes and to the superintendents matrons and
Icaclicrs who helped with the actu il mspcctions In the case of
the privalc school children we thank sincerely all the pnncipals
and teachers who so willingly gave us time and assistance to
further our researches We also much apprcaated the help given
by Miss Irene Allen of the Medical Research Council s Siaiislical
Department
REITRCNCtS
Anderson P G Williams C II M Haldcrson H Summer
fcldt C and Agnvw R G (1934) / Amer dent Ass 21
1449
Collcil A (1935) Tidsskr nnrske Lneeeforen No 22
Coumoulos H (194(0 Nature Load 158 559
and Mcllanby Nl (1947) British Medical Journal 1 751
Davies J It (1939) Bnl dent J 67, (6
Dcvcrall A (1936) Spec Rep See rned Res Coun Land
No 211
King 3 D (1940) Ibid No 241
(194(0 lancet t 646
Mcllanby M (1923) Brit dent J 44 I
(1934) Spec Rep Ser rned Rex Coun Lend No 191
and Coumoulos II (1944) British Medical Journal 1 837
(19461 Ibid 2 S65
and Mcllanb) II (1948) Ibid 2 409
Mcllanby II and Mcllanby M (1950) Ibid 1 1341
Ministry of Poo I (1947) Our food To das No 3
Scliiotz, E H (19491 Bril deal J 66 S7
S(oncs H II Luwaon P I Bransb) E R and Hartley H O
(1949) Ibid 86 263
rosTcnioR gastro-enterostomy
IN PEPTIC ULCER LONG-TERM
RESULTS
n)
DOUGLAS H Cl ARK, Oi 1\1 , T R C S Ed,, F R F P S
(from the Peptic Ulcer dime llVSffrri Infirnwo Clasgott)
Gistro entcrostom) in the trcitmcnt of peptic ulcer has
been the subject of many reports, often conflicting and
in recent vears seldom fivourable Although today
abandoned by manv there arc still some who champion
Its cause In this country Sir James Walton (1950),
on careful and complete follow up of a large senes of
cases, has found a constant incidence of stomal ulcer of
only 2% but most other workers put the figure much
higher, even as high as 40% The results obtained by
Heuer (1944) agree with the experience of the majority
of recent writers In his senes of 159 cases followed
for periods of 3 months to 10 years (85 followed from
5-10 years) 21 4% developed recurrent s)mptoms
In comparing the end results of gastro entcrostom)
and gastrectomy, Heuer found on both short term and
long term follow up that the outcome was 10% in
favour of gastrectomy but as he pointed out this
advantage is reduced by Ihc lesser immediate mortality
of gastro enterostomy To the debit side of the gastrcc
lomy will hue lo be added a still undetermined but
probably considerable percentage of unsatisfactory results
in the form of small stomach ’ syndromes It is also
probably fair criticism of the more extensive procedure
that when medical men, and especially surgeons con
tcmpinic operation as a personal issue gastro enterostomy
IS given more than fleeting consideration
With such thoughts in mind, it was felt that a further
report on the results of g istro enterostomy stressing the
long term results, would be of interest
Clinical Malcn il
The material in this rcsicw consists of 330 patients
subjected to gastro enterostomy for peptic ulceration
during the 14 years between J iniiary 1, 1924, and
December 31, 1937 All ciscs were under the care of
one surgical unit in the Western Infirmary, Glasgow
58 Jan 13, 1951 POSICRIOR GAS! RO RNTFROSIOMY IN PERI IC UI CLR
All cnnic from G1 i<;qo\v ^n(l ndjiccnt di'itricts The
nnjonU were ci?cs of ticciivc op rntion In m’C oaia
gTitro cnluroslom) w is performed U ll’c time of closure
of a pcrfontion In two casts (astro tntcrostom> with
ligation of vessels was performed for hitmitcmesis
I ollnw up
An attempt was m ide to trace all the survivor' and
recall them for c\ munition Altoi ether lf>5 patients
Were trittd and were interviewed 21, now at a distincc
in the U K. or ibroad tould he contacted ont> l)>
letter question irv With the aid of the a'lnon-r Red
Cross workers mil other vohintirv or( ani/ations 50
Were triced and found to have died I he inform ition
available from their records relatives, f imilv doctors
and death ccrtificitcs allowed of some isscssment illicit
second hand The rcnuiininr 70 despite all effort
rem lined untraced Manv of these pitients had lived in
an arc I which had siilTered from eneniv iction Ihc
total number of ciscs traced includim 21 opentivc
deaths was 2(!0 out of 310 — that is 7S 7 The mi cs
tigation was carried out during 19-1'? and 1919
It IS probvbli inaccurate to cl urn this stud> as a
follow up Recapitulation would be i more ipt term
since manv of the ciscs were being seen for the first
time 11-22 >ears after the event Where patients were
known to have reported to other hospitals at home or
abroad, inform ition was obtained from these hospitals
The distribution of the cases bv oper ition >car .md
their appropriate places in this follow up arc shown in
Table 1 Table II lists the cises according to dn( nosis
T*BLn I — DUIrtbullon of Opfrn Ion Siini\orj by leer of
Opfrptlon
Ycir
Trace il
Al«»e
Traced
Dead
Untra-^d
Toul
1924
2
2
4
8
192J
f
2
1
)
1926
10
2
(
IS
1927
9
1
7
17
19.8
12
3
7
24
1929
14
1
4
19
1930
17
3
6
-8
1931
22
5
6
33
1932
20
2
6
-I
1933
17
7
5
21
1934
21
8
5
34
1935
8
6
5
19
1936
14
0
3
17
1937
n
4
5
23
186
50
70
306
Tahlc II — Disinbution of Operation Siir\l\()rs by Dlajinosls
DloRno^is
Traced
Alive 1
1 Traced
1 Dead
Untraced
Total
Pyloric stenoMS
19 1
7
5
31
Duodenal uJu;r
136 i
30
61
247
Gaatnc ulc4.r
11
13
28
186
1
50
1
70
306
Asses^meut of Re^idtK — Tl^c rc^ivilts h'xvc been (Imdcd
into (a) satisfactory — those entirely free from symptoms
— and (b) unsatisf ictory — those who at any time since
operation (I) have had pam of ulcer type (2) have
suffered from hacmatcmesis or mehena (3) have been
treated in hospital for medical or sur<,.ical treatment of
peptic ulceration (4) have had x ray evidence of stomal
nicer or reactivation of the original ulcer
Grades of Seventy — The cases grouped as unsatisfac
tory vere not all poor results Many though not cuicd,
benefited by the operation Accordingly these results
P*m«i
^frirtCAL i<r
were further gr id"d into (n) severe — pain as scvcrcasor
more severe th m before operation , those who lud com
phcitions or who had required iiirthcr oper ition hccatisc
of p'ptic tiRer (b) Modcr itc— pam less severe and
more e isitj controlled bv food and all alu (r) Mild—
pun slqht infrequent and v' ith djspcpsii (flatulence
lieirtbiirn etc) winch required diet rcvttietioas md
all ah therap) mioimting to some limit ition of the
normal mode of life
I iiiliiri Cline — Ihc onset of sjmp'oms after opera
fion Ins been dilcd is ,accurilcl> as possible The p-r
eentage of iinsatisfaetor) results for eaeh follow up
)cir for the entire senes of pitients traced (cacluding
the immediate past op-rative elcaths) sv's cilciilatcd and
plotted in i fit lire curve Simil ir curves were plotted
scpiritel) for severe modcr lie and mild relapses It
should he noted that for thi stud>, anv pilicnl who had
sjniptoms whieh miounled to m unsaiisfactorv result
vs IS considered as such from the onset of the recurrence
through the rcmtinine vcirs of folios up that is the
curve was charted on the basis once i recurrence alwavs
.a reeurrcnce llicrc was no moelification of the cunc
for those who for cxanip'c hidonlv four sears ssanp-
loms in IS VC us of follow up Sirnilarlj, those cases
modified b) fiirllicr surgieal or medical Irnlmcnt were
repuded IS fiihircs fton the ons't of ssanploms This
method no doiihl rep events a more glooms picture thin
a jcir to veir assessment would but in view of the j cats
tint had clipscd since operation it was thought that the
more simple method was a sulheicnt tax on the m-mor)
of the patient and limited the scope of his imagination
Resnlls
Tile relapse rates for >cars 1-20 have been calculated
but onl) those of the first five )cars and for the 10th
15lh and 20lh >cars arc listed in Table 111 The failure
curves for totil severe, moderate, and rtuld relapses are
shown in 1 le 1
»t ?t I
Fio I — Inciilcnee of totvl severe modcrolc and mdd relapses
Tantr III •^Ctimtihlbe Inclitence of Retapses
Year of
Follov. tip
Obverved
1 Percentage Rclap«»
Severe
Mcnlerate j
Mild
Total
1
■‘36 I
8 89
1 27 1
043
10 59
2
2 8 1
14 47
4 3S
195
2 80
3
2-6
IS 14
5 75 i
7oa
K»97
4
•• 4
17 83
5 81 1
8 48
3“* 14
5
2 1
19 45
6 7) 1
9 1)5
35 29
iO
21M5
21 30
8 73 1
11 16
4t 19
IS
IM
-5 18
9 .2 1
9 ..
4162
20
40
25 00
17 30 1
*0 00
6. 30
It Will be seen that the incidence of relapse is most
marked in the first live years 35'V having relapsed at
the end of that period Tlicrcaftcr there is a slower but
Jan 13 1951
POSiruiOK O ASTRO ENTLROSTOMY IN PEPTIC ULCER
BRrnsii
Medical Joursai
59
sleidy increase in incidence In approsim He figures it
maj be said tint after a p"nod of beuveen 15 and 20
scars 50% base remained ssmptom free Compared
ssith their pre operatise state 12 S were markedls
improved 12 5%, though improsed stdl suffered con
siderablc disability, and 25" were no better or worse
In other words in 37 5" the results left much to be
desired
Factors Influencing Results
The total relapse rates and the cumulatisc incidence
of scscre moderate and mild rilipscs were calculated
separately (I) for duodenal ulcer castric ulcer and
p>loric stenosis (2) for males and females (3) accord
ing to age at time of operation and (4) according to
length of pre operatise histors
1 Duodena! Ulcer Gastric Cher and Py lone Stenosis
— Of the eases traced 1S6 were duodenal ulcer 24 were
gastric ulcer and 26 sscrc psloric stenosis It is neces
sary to define the last named group for there arc many
degrees of pjloric stenosis and it may be organic or
« I I
Flo 2 — Companion ol total lelapscs in duodenal ulcer gastric
ulcer and pylonc sicnosis
spasmodic or both In this paper eases svcrc assigned
to this group svhen there was x ray evidence of consider
able retention and when copious vomiting characteristic
of gastric delay, was present Pam was not a marked
feature of these eases The total relapse rates are com
pared in Fig 2 In the duodenal group the relapses
mount rapidly to 35% in five years In the subsequent
15 years a further 27% recur In the gastric ulcer group
the large failure rate in the first five years is partly
explained by six cases of carcinoma of stomach the
operation having been performed in the belief that these
ulcers were siriple In the group with obstruction
though considerably better, the relapse rate is sur
prisingly high — approximately 25% However, it was
noteworthy that in cases of pyloric stenosis the relapses
on the whole were less severe in marked contrast to the
duodenal and gastric ulcer groups in both of which the
incidence of severe relapses was considerable (25% at
the tenth follow up year)
2 Sex — In the series traced there were 200 males
and only 36 females In Fig 3 the incidence of total
and scscre relapses is plotted In view of the disparity
of numbers fair comparison cannot be drasvn howeser,
the impression is gained that whereas the total relapse
rates are similar the incidence of severe relapses in
females IS markedly less
3 Age at Operation — The cases traced were placed
in the following age groups under 30 (44) 30-39 (81)
40-49 (60), and 50 and over (51) The total relapses
are compared in Fig 4 The findings show that the
results of gastro enterostomy arc better in the older age
groups Though not recorded in Fig 4, it was noted that
the incidence of mild and moderate relapses was much
the same m all age groups The better results in older
patients represent a lower incidence of severe relapses
KKt 1 Ct
UK MKL
Fio 4— Total relapse rales according to age group at Ume ot
ope ration
4 Duration oj Pre operant e Ulcer History — In order
to study the relation of the end results to the pre
operative history the cases have been allotted to four
groups according to the duration of symptoms prior
to operation The number of cases in these groups is as
follows 1-4 years 66 5-9 \ cars 76, 10-14 years 57
and 15 years and over, 37 The result is shown in Fig 5
from which it will be seen that the total relapse rates
arc closely similar in the different groups Although not
shown in Fig 5, it was noted that the incidence of
severe relapses was considerably higher in the 1-4 years
group than in the group of 15 years and o\er As an
example, at the tenth year the short duration group
gave 30% severe relapses compared with 11% in the
long-duration group TTie better results in the last group
Pio 3 — Comparison of total and severe relapses in males and
females
Fio 5 — Total relapse rates according to years of duration c,
pre-operative history y
CO n 1051 POST TRIOR C. ASTRO CNTCROSTOMY IN pcnnc UI UK
w ^ ... ^ , . „
nrc probibI> due to tlic fnct tint it contnini a hi} her
proportion of older paticnti of women piticnte and of
piticnts with pvlorit •itcnoei': Tlic rtsiilts in the ^-9
jcir and 10 l-l jcir (roup? arc simihr and mtermerhate
— for example the ?e\cre rchpee rites it the tenth >cir
beine 27' iiid 23'\ rcspecliscR
IiichUnec of Major Compile illoiis iind I^tc Deilh?
Oier the totil fo'low up pmod pistro intcstiml
hiemorrlnic occurred in 20 piticnts (12 29) Tlicre
vs ere Inc perforations m four patients in incidence of
2 I Mi Nine pitients (t S ) found it ncv.c»Mr> to
underfO furllicr opcrition for relief of svmpioms f our
of the pitients alrrulv noted is Inviti}, suvtuncd a
lncmorrln}e also elected to iindcrpo i further open
tion Thus the ‘ li ird tore ‘ of recurrences inioimtcsl
to 1SI% Almost two thirds of these severe tchpscs
occurred within the first Inc veirs No cave of pastro
jejuno-tolic fistula vvas entountered in the senes traced
1 iftv of the pitients tritcvl we c found to have died
In the 111 ijorilv the cause of dc ith vs is unrcliiiet) to
pcp'ic ulcer Tour patients died from tames directl>
attribut ible to peptic uIccr~two as a result of pis
trcctom) for stomil ulcer and two as a result of
haemorrh iic
In SIX of the pastric ulcer cases traced the cause of
dcith was circinomi of the stomach In onl) two of
these was ncvropsv performed in one ni ihpnnnt chanpe
had supervened on i simple lastnt ulcer In the other
case nctrops) details were not n iilable Hiree died
within three jeirs, the renuinder within Ine >cnrs
Gastro cntcrostoni) In leavmr the ulcer eirries an
immediate risl of nintatcn diipnosis iiid a later risk
of milipnint change Circmomi of the stomach was
the tausc of death m tlircc cises of duodciul ulcer
death occurring at 10, 12 and 17 jcirs after the
opcrition
Discusviun
Ihc results of this invcsiipition conlirm the hiphcr
relapse rites reported in tilt liter mire It must be
stressed, however that the method of issessmenl used
has presented the results of the operilion m the worst
possible light A jcartojcir assessment would no
doubt present a more pie ismp prosp.et Manv thouph
not ‘ cured were consider ibly improved Aincinp those
were sever d who had siilTcred a compile ition as an inci
dent in an otherwise uneventful post opcr,itive history
These cises iccordmg to the criteria used were noted
as severe relapses Similirly, a few eases hid a total of
only about four years stom icb trouble in ns many as
15 follow up ycirs Viewed from the vantipc point of
cure of peptic ulcer by oper ition the present results
assume a proper perspective In round figures after a
period of 15-20 years 50 {, rtm lined symptom free
and 12 5% whose symptoms were slight were markedly
improved In the rcni lining 37 5% the operation had
failed
In view of this high fiiluic nte it seems pertinent to
try to obtain a true assessment of the value of the opera
tion To do so it IS necessary to compare the results
obtained with those expected without treatment and with
those obtained by other methods of operation — for
example gastrectomy Furthermore, since gastro
enterostomy possesses the cardinal advantage of low
initial mortality, the question arises how casts liktiy to
gam permanent benefit by this procedure might be
selected pre operatively
t nniparhon wllli I'nlmlti! Ca n
Ohvioiisly It IS not now possible to obtain for study
ns a control in untreated iroop of cis*"- stricilv com
parable with tlio'c repined above Information regard
in} n somewh It stmil ir }rmip of t v v is however av>d
able from tlic tollow up sludic of Illmgaorih rl cl
(1916) These studies refer to the pro revs after per
forited peptic ulcer and relate to pitients from the seme
region ind of the sani" sncp! class Ihc •'■e and «ex
distfihiilion in llic tvso senes arc rcmarlably simiia'’
and by a toinculentc the p'oportion of gavt'ic to
duoilcnd ulcvtv IS almost idcnticil The two are
similar at o in lint ificr disclnrg’* from hospital thci
dietary co itrol and anti ••cid tre itmcnl were gcnenllv
haplnrard Pitients in the rastro cnicrostnmv coup
with pvloric siciio IS have h'*cn exvludcd siacc onstruc
lion IS not a factor m lit* petfortt on senes rd would
b, inclusion improve the results of the ptcsenl «c ics
They dilfc of coiirs- m that la tic Illnewonh series
the sole criterion fo' in liision vvas Ihc fa^t of ji* fo a
110,1 and in onlv a smill proportion hid the svmplomv
Is^forc perfo alion been severe cno igli to warrant surgi
cal tre Itmcnl tiles'- two dilTcrcnecs wou'd seem to
imply a b*llcr pro na'tv av re; itils rcluf of svmp’oms
and so m comp time the results the sc-dcs woild be
weighted against the p esent senes
In I ihlc IV the incidence of rvlapes m die present
senes and tint ifler petfot ition ate compi cd at the
cnvl of tlic fifth follow up year I ig f> shows tlic yeir bv
year comp in on for the lust live vears In I ib'c V and
Tviitr IV — rne)e ' hr’ "in Ct grr/ios *n’li Per) r-fws
Crrin
TamJ* V — of tony
Lotf\j /i( n HI ^ rctfi tc ion Sr'lO
1 of i
1 t * ' i
ii-*-
C Hi att-vni
PfTvni
>’ 1
! 10 s
Tcff >r«ll nv.ri '(lUit ^ rf M
(S text) 1
t ''lO
Tip 7 the incitlLncc of major comphcilions is similarly
compircd Herv however it should be noted that
Illiniworih or nl (1945) arrived at Ibnr csliiralc on the
basis of lfi6 pitients f^ollowcd for the full five years
but used additional informition from pitients followed
for shorter periods
Compirctl with the untre itcd group, castro
enterostomy his halved the relapses and the
complications
Ct)mi)arifon »lth Cmcn Trrntetl b) Cn^trrftnm)
Though the results reported for' gastrectomy viry, it
seems clear tint recurrent ulceration is infrequent not
more than 4'\' (I until 19''0), and in more extensive
abl Ition of the stomach (Visick 194S) this complication
has been reduced to nil Comparison on this score
atone leaves no doubt about which operation is prefer
able The position becomes less clear, however, when
assessing the importance of those disturbances of all
mentary function which arc the sequelae of gistrcctomy
There is no unimmity m the reported results is regards
the incidence, seventy, and duritcon of these comphea
Jan 13, 1951 POSTERIOR CASTRO ENTEROSTOMY If^ PEPTIC ULCER . oimra 61
Meoicai, Journal
incidence advocated the use of gastro enterostomy, particularly m
7o
YEARS
Flo 6 — Companson of rchpscs after gastro-cnteroslomy with
tho'c after perforation
tions Muir (1949) found that 75% of patients in his
scries suffered at some time from the dumping syndrome
and that m 34% the patients were considerably handi
capped According to the same author, although this
complication sometimes disappeared within three months,
not infrequently it persisted for years That they arc
better off with their dumping syndromes than with their
peptic ulcers is readily admitted by most patients— but
not by all (M D 1949)
Comparison on the basis of recurrent ulcer is in favour
of gastrectomy by a wide margin How much this
- margin will be reduced by small stomach syndromes is
as yet tinl nown
Selection of Cases for Gnstro enterostomy
The occurrenec of good results in at least half the
cases has encouraged previous authors to inquire into
methods of selection For example many surgeons have
PERCENTAGE
INCIDENCE
y - A n 5
Fio 7 — Comparison of complications after gastro enterostomy
with those after perforation
elderly patients with a long history, in women and in
patients of either sex with severe pyloric stenosis _ Refer
ence has been made above to the results to be expected
in these different categories of cases
The pre operative gastric acidity has been used as a
criterion by some surgeons on the hypothesis that stomal
ulcer is less likely to occur if the acid level is low
Several workers have found this criterion unreliable
For example Holman and Sandusky (1938) and Nicol
(1942) found little relation between the reduction in the
acid concentrition and the clinical improvement pro
dueed by the operation High pre-operative and post
operative levels of free HCl were consistent with good
results On the other hand severe relapses were encoun
tered in patients with low acid levels before and after
operation
Taylor (1944) has based selection on gastroscopic
appearances and has succeeded in reducing the incidence
of recurrence to a low figure Where the mucosa is very
vascular and the rugae exaggerated relapses tend to
occur after gastro enterostomy Gastrectomy is advised
in these cases
Walton (1950) is convinced that certain people are
more prone to develop gastro jejunal ulceration Such
patients tend to develop duodenal-ulcer symptoms early
in life , there is a high free acid response to a test meal,
and both radiography and gastroscopy reveal hyper-
trophy of the mucosal folds
Visick (1948) carefully examined stomachs removed
because of recurrent ulcer Abnormally extensive
mucosal folds were not a noteworthy feature
Conclusion
In gastric ulcer in view of the high relapse rate and
the possibility of mistaken diagnosis and malignant
change, the operation of choice is gastrectomy
In duodenal ulcer the present investigation suggests
that the short circuit procedure has a place in the elderly,
in women, and in organic pyloric stenosis These factors
however, carry no guarantee of permanent cure With
regard to the large proportion of duodenal ulcers requir
ing operative treatment until some means of selection
IS forthcoming, gastric resection will remain the most
certain method of cure, an opinion which may require
some modification when the true incidence, severity,
and juration of post-gistreclomy syndromes are belter
known - -
I am indebted to the tale Mr Roy F Young and to Mr George
Dalziel for permission to use their records I also wish to tliank
Professor C F W Illingworth for his helpful cnticism
References
Heuer G J (1944) The Treatment of Peptic Ulcer Lippincotl
London
Holman C and Sandusky W R (1938) Amer J mea Set
195 220
Illingworth C F W Scott L D VV and Jamieson R A
(1946) British Medn'al Journal 1 787
Lancet 1950 2 373
MJ9 (1949) Lancet 2 907
Muir, A (1949) Brit J Siirg 37 165
Nicol B M (1942) Lancet 1 466
Taylor H (1944) Proc R Soc Med 38 95
Visick A H (l948) Lancet 1 505
Walton J (1950) British Medical Journal 1 206
A free booklet District Ntirsttig in the Metropolitan Police
Area gives the names and addresses of all the nursing
associations in London It is available on request from
the Central Council for District Nursing 25 Cockspur
Street, London, S W 1
f )2 Jas n lyM
IRON rNCEPIIAIOPATHY
nv
C. AIIAN niKCn, Ml) I lie I*
A*>r)
MOUWINNA inu Mil. IlClilr, I) C 11
(Tram Char Itrm UotpUil InfrlJl
The problem of rcfnclor\ mtcrocMic l)vp>thromlc
-imemn Ini been latisf lelontj sohetl in nnn\ t ties
b\ the intr ivcnoni ndnitnistnlion of an iron Microic
complex (Nixmii 1917) Nexcrihclcsi iron bj intri
\enoiix injection nncl c\en b> mouth ix not cntircl)
without risk Iron poisoninp wax quite common for
some xenrs .ifier PKrre Illuiil introtluccd hix finnui
pill in 1812 No further casex xxctc reported until
recent >carx when after a period of nejleet, the prac
tiec of pixine inorpanie iron xilix m lirpe doxes b>
mouth b-came cxtablixhcd ae iin ax iixcfiil treatment for
hxjochromic anaemia Rcccntl> ferroux xulpliilc b)
mouth has cauxed acute paxtritix and death from hepatic
f ulurc
Cerebral xjmptomx follow inj oral iron niedieition in
man arc rare llurxt (1131) reported the case of a xerj
anaemic xxoman of 58 (lib 18' ) xxho too) 10 pr (26 p)
of iron and ammonium citrate a da> On the 22nd da>
of treatment (her Ilb liaxinp risen to 5 1'') 'he com
plained of xexcrc headache and had nine conxulxionx
within 24 hotirx flctwcen the altaclx xlic wax xcmi
conscious and had twitching of the riibt xidc of
the face She made a pood recovers R-xond xixing
that the cerebral x>mptoms rcicmbled those of lead
cnccphalopath) llurxt pave no opinion on their
mechanism and lux title ‘iron encxplnlopatli)
seems I ardly justified on the data published
Napier (1936) reported a case of presumed iron
cnccphalopathj in an Indian man aped 30 who after
receiving 46S gr (30 p) of ferroux sulphate in 26 days
for a simple hypochlorhydric anaemia (lib IS” ) had
a senes of seven fits during a day lie also refers to
tlic case of n wom'’n who had fits following a daily
dose of 12 gr (08 g) of ferrous ammonium citritc for
33 days Whether the iron had been responsible or not
seems doubtful, ns the Wassermann reaction was
strongly positive
Mooney (1950) mentions intense headache follo’xving
an intravenous injection of 100 mg of saccharated iron
In the case recorded below severe cerebral symptoms
occurred after the intravenous administration of iron
Cnsc Report
A houncwjfc Tfcd 54 of 'wenge mcntnl cipicdy attended
hospinl on Jininry 12 1949 uiih n history of mcrcising
dyspnoea and lassitude for three ycira and of ocdcmi of
the ankles incl soreness of the tonj-uc for two months
She had no dysplntia Her menses had been heavy until
September 1947 when ihcv ccisccl There was no other
h story of blood loss Her diet hid been intdcqiiaic though
she had not lost weight There had been no previous
illnesses and she h id had two normal pregn incics
On admission the patient appeared pale There was no
glossitis The pulse was regular the b’ood pressure U>0/70
The heart wis not enlarged A soft systolic bruit was
audible over the praccordium but was not thought to indi
cate valvular disease No abnorm ihiy was found in the
lungs abdomen pelvis or central nervous system
Tintat
VtimCAl /eXTHAL
/nirifD.i/miit-— lib 41 , (6 p V ) R D C 3 -00 000 j'tr
c mm ciilfiiir int'ex Ofi rciiciilocylcx Icxx than 1'
\\ II C 7 100 per t mm - tlillcrcntul coiirl rorrril A
fiictionil Icxi mcx1 xhowctl hwlxmine f'xt achloihyilria
A tulini'npli Ilf the tlicu w ix num al Ilic iirire wax
luifnnl A xliipnmtx uf bypocliromit microcytic (iron
ilclicicncj) an icmn wax made
I rofiTtx «r><! Trratmmr
Intraxcnom iron tberapy x ax bet-un ti Inp a xo'ulion ol
lacelnraled iron oxide (containinj. 100 mp of iron n 10 ml).
On ll c a xiimpinm lliai eaxb I(io mp of iron ihould rai«e
it c !i icn oylnbin b> 4'i ibe lolal rcqiiircmcnl for Ihii paiienl
wax 1 *P0 mp
On Janiiaix 11 and is rexpccluely 20 mp and <0 mp
xxtre vixen lb- inj'tlionx temp naadc xlnwly into a xem in
llie anlcvub tal fi xxa Oa ibe 17lh afier rcccump -0 nc
of the iron ibe pali- il complained of di74incxx and o'
tinpbnv in the li-ndi Mie alxo xialed lliat cxcrylbmc
app'ared 'tnpy Sbe ih-n xoanlcd The injcc ion
xxax dixcoatirii-d Afier ihix mi'ctionx were contini-cd
xiaily none of ihcm I— mp pttilcr than 75 mp Only
minor comptamu of naiix-a and general malaixc were
made
lly jam ity 23 lie ninth dax afier Ibe initclionx x -re
xtaricxi a to'al iloxe of I'O mp of iron bad been adaiiai'
tered On ibix day the palicnl complained of hcadach* and
app-ircd In be very anxiot x Sbe taler xomilcd twice No
injection xxax vixen Al 7 10 pm the mirxinp xia(I not'd
that xltc xeemed xtranpc in Ii*r manner and somewhat dtoxx-xx
At 9 10 p na xbe had a conxubion, after xxhich x! e remained
xlecply un.oaxvioiix Her Iim‘'i were flaccid and her exex
(I'xialcd lo the tithi Her pulxc rale xxnx 120 a mmu c and
lie tlylhm irrcjiilat There xxax ro pulxe dcfcit I util e
corxiilxiotix then oenirrcd al mterxalx of about 20 miriiicx
Ijcli of llirxc bepan in the lefi hand and spread to in'Iule
the left xide of the fate the left Icp and finally b-camc
genet ili.ci! Tlie C S I prexxure xxax 210 mm and routin'
laboralorx exammatu nx shiw ed no abnormality TTie
Wax etmann reaction xxax n'patixc in both the CSF and
the blood I arpe doxcx of panidchxde (16 ml in all) were
pixcn intrinnixctihrly but the conxulxionx bccan c more
frequent until it I am on January 2) they were recurring
at fixe minute inicrxalx Tlcrcaftcr they ixecame Icxs ftc
quent and were confined to the left side of the bx’dx Thex
finalb ccixcd at 4 a m
The piiieni remained iinconxctoiix during the next 12
hours but rexponded lo pinchinj by proaninj, or by moxinc
one or oilar lej Many mnule pelechiic were xixibic oxer
the chcxl and armx and bruixinp had oamrred al the sites of
pinchinp A mild left hemiplegia aflccting the arm more
(Inn the lee was present this gradually improxed diirine
the next three days Her blccdmi. lime xxa- 40 seconds
and the clotiinj lime fixe minutes platelets numbered
13 X 000 per emm the capilhry resistance test (Rumpel-
Lecdx) xxas posiiixe and the urine xxas normal
tty January 28 the patient xx-xs conscious and rational
She xxas able to xxrite and to read a fexx xxerds correctlx
but iiinbic to understand xxhat she read Al 5 45 pm she
suddenly lapsed into a drxanix stale She sal up in bed and
appe ircd to be eomplctclx detached from her surroundincs
making no response lo the spoken word or lo punfiit
stimuli The fexx xxorde she uttered (which often included
green’ mil xcllow ) indicited a cross dysphasia
Altliough tins speech defect xx is associUcd with a left
hcmiparcxis she x\ is not left handed The only other sign
of note was the presence of spontaneous nystagmus This
ditamy stitc lasted for 10 hours
By March 8 she xx is able to read accurately but a
tcmlcncy prcxiously noticed to re id onK the right halt
of printed lines persisted Her xisuil fields were appar
cnily full but cooper ition was poor Her general condi
lion was pood and she xxas able to xxalk xxiih issislancc
She complained intermittently of occipital hcadiclie The
IRON INCLRIIAIOI’MIIY
Jan 13, 1951
IRON ENCEPHALOPATHY
ORmsH
Medical Journal
63
hacmalological response (o the iron ssis e\ccllent There
had been a good reticulocjtosis and the haemoglobin rose
steadily to 82% (12 1 g‘\) on Februarj 2
She was discharged from hospital on April 1 and returned
as an out patient on April 30 Her haemoglobin was then
92‘’o (13 6 g "o) There were no abnormal physical find
mgs but she still complained of headache She was very
anxious and she easily panicked Though able to carry
out simple household duties she could not cook a full meal
or do any shopping and was quite unable to make any
calculation or to count change She has remained more
or less in the same condition eser since but has become
increasingly depressed at the persistence of her disability
of which she seems fully aware Her haemoglobin level
on June 1 1950 was 106%
When last teen on June 24 1950 she was a littlcHmsteady
on her feet She was depressed at times and tended to be
muddled over money These symptoms were less marled
than they were originalK An electroencephalogram at this
time showed evidence of bilateral damage m the temporo
parietal regions
Discussion
Two well known proprietarx preparations have been
used many times in other cases without serious mishap
On this occasion both were out of stock and ampoules
of a privately made preparation were offered instead by
the pharmacist and accepted for use It was not fully
realized by all concerned that this preparation was other
than had been safely used before It was a solution
of saccharated iron oxide prepared from fern oxid
sacch equixalcnt to 100 mg of elemental iron (Fe)
and apyrog n (pyrogen free distilled water) to
10 ml The saccharated iron oxide was dissolved m
the dpyrogen with the aid of heat and the solution
was filtered through filter paper while still hot It was
filled into ampoules and autoclaved at a pressure of
10 lb per sq in (0 7 kg per cm ’) for half an hour
Subsequent analysis of the preparation showed that it
contained the correct amount of elemental iron (Fc)
and 21 6% of sucrose the pH being 8 7
Compatibility with serum in iilro was demonstrated
by mixing 2 ml of the solution with 2 ml of normal
horse serum and 0 1 ml of the solution with 5 ml of
normal horse serum These mixtures were incubated
at 37 C for one hour and gave no macroscopic or
microscopical evidence of coagulation or precipitation
Similar tests with the patient s serum and that of normal
human controls were negative It must not be assumed
however that precipitation would not occur in vivo
and Nissim and Robson (1949) found evidence in mice
that a gradual precipitation of proteins did occur m
VIVO and suggest’d that the compound was broken down
gradually as the sugar part of it was metabolized The
LD50 of the sample administered intravenously to mice
was approximately 118 mg per kg whereas the most
suitable preparations were found by Nissim and Robson
(1949) to have an LD50 of 300 mg per kg
The available evidence does not satisfactorily explain
the production of cerebral symptoms The importance
of using pure chemicals in making saccharated iroti
oxide IS emphasized by Robson and Keele (1950) who
point out that some of the more transient reactions can
be avoided by using analytical grade reagents — ^for
example 'analar sucrose Somers (1947) showed
that very large doses of iron preparations given by
mouth would kill animals resulting in convulsions and
coma for which no adequate organic basis could be
found Cappell (1930) studied the fate of intravenous
injections of colloidal solutions of saccharated iron
oxide in mice and rats They did not cause floccula
tion in contact with plasma and so pulmonary embolism
did not occur The iron was taken up by the cells
of the reticulo endothelial system, and later formed a
loosely bound compound with plasma proteins through
which It was distributed to other organs notably the
liver Some iron was deposited in the walls of the brain
capillaries but it was rapidly removed and thereafter
no iron was found in the nervous tissues It is con
ceivable however that capillary damage, sufficient to
lead to sub^cqucnt injury to the brain might be caused
by some iron preparations
Poison (1928) in attempting to produce haemo
chromatosis in rabbits by injecting dialysed iron intra
xcnously, found that pulmonary embolism presumablv
from flocculation was easily caused bv long or rapid
injections Ledofsky (1924) injected a 33°' solution of
saccharated iron several times into eight moribund
patients but no iron could be demonstrated in the
brain tissue histologically Goetsch el al (1946) attn
buted the toxic effects of iron to a heavry metal effect
but this term is usually understood to mean the forma
tion of a metallic proleinate when a soluble metallic
salt is mixed with a solution of protein We know that
in the present case the preparation used did not pro
ducc a protemate with the patients plasma
The analogy of lead encephalopathy is not help-
ful, since the pathology of this state is unknown apart
from the findings of arteriosclerosis and meningeal
fibrosis in chronic case?
Summary and Conclusions
A case is reported of severe cerebral symptoms m a
woman aged 54 after the intravenous administration of
380 mg of iron in nine days The symptoms are tenta
lively ascribed to iron encephalopathy but the mechanism
of their production remains in doubt The use of certain
proprietary preparations of iron for intravenous use is
known to be valuable and fairlv free from toxic effects
if these preparations have an LD50 for mice of 300 mg or
more per kg and if dosage is kept below 100 mg of iron
a day The danger of using unproved preparations is
emphasized
RCFERbXCES
Blaud P (18321 Bull gi^n Thtr Pans 2 154
Cappell D F (1930) } Palh Bad 33 175
Goeisch A T Moore C V and Minnich V (1946) Blood
1 129
Hurst A F (1931) Gin s Hosp Rep 81 243
Ledofsky E (1924) Wien klm Wschr 37 694
Mooney F S (1950) Bnlish kledieal Jnnrnnl i 1267
Nanier L E (1936) Indian nied Gaz 71 143
Nissim J A (19471 Lancei 2 49
and Robson I M (1949) Ibid ) 686
Poison C 3 (1928) J Faih Bad 31 445
Robson J M and Keele C A (1950) Reeeni Adiances in
Pharmacoluev p 285 London
Somers G F (1947) British Medical Journal 2 XQ!
On Mav 31 1950 the Royal College of Obstetricians and
Gynaecologists comprised 837 Members and 322 Fellows
Seventy three of the Fellows belonged to the London divi
Sion and 1 iverpool and Manchester togeiher contained 20
the greatest concentration outside London Out of 31
Scottish Fel'ows Edinburgh contained 11 and Glasgow 14
in Ireland 9 were in Belfast and 13 in Dublin while
Melbourne and Sydney (Australia) md Montreal (Canada)
had 10 Fellows each
r.t n Ml inniN in iri a
MnnoiN IN inr iRHA'iMrNT oi
I Pii i:rsY
ii>
t) R JONtS MI) MR CP
Mrhctil /v< ^tri r \/(i I nic UmptUtI fur Str\i u\
Onriiij li ir Uei^nln r \U II t iil
Diirini ific Iivl \eir'5 •cicri! nc \ inti cpilcplic
ilivus insL bcciime n%-\ihWr for cltniv.!! ihc of lli- c
Irovulonc ( Indioiic ) t welt Inown in tiu trcitmcnt
of petit mil liiK piper II i repot on n trnl of
metlioin ( incsontoin 1 nictli\l-5 5 p’ien\lcth>l-
hvdintoin) \ ptepuition miml'i cffcvlisc rpiiiul
otlicr \ lrl^llc^ of ipi!cps\ llie driu i lIiliiih. ills
Tilled to phcnMoin tind n tPo rehted to tlie toxic »lrii-
plicn\lctli\llud iniom ( nirvinol ) nnd to iroxidoric
(IUi>;i m 19 IS)— I f ict of xoinc xi} ufiem e when im
ndtrin!; itx toxic ilTectx It ix di'penxctl "lx < pml tiMet
of 0 I p
Clinic il In ilx were firxt nnde in 19)7 In 11 diet (I‘> tl)
wlio rcr irded it nx xilinblc but potertti ilK toxic Reniltx
were lirxt published in Aniern i in l'*!^ since when
minicrniix reports upon its inc line licen iipde thini' h
no dtliilcsl stud) Ins ipp'-irsd in the litstiliiri. of Ihn
coiintrx
I osni/o (I9!5 I9lfi 1947 I9!s) inmr ^o Inini
dipbcnvllnd intoin lie ( dilinlol ) in n font seir stud)
reported i fi07> rtdiution of fits in pitienlx xiiffcrinf
from m ijor and niinor cpilep ) I oxn. clfccts wcie few
ond the ibscnce of turn lijpertropln tiuI itoxn (tom
mon to'ie xjmptomx nitli pbcn>tom) w n lU) tb’c ko/ol
(1916 19)7 1950) lisin! doses of up to 1 S f i dn
treTltd 200 pnlitnls for periods of up to four \cirs nnd
found 1 90V rcdiitlion m frequent) of Ills csen iluniib
the mnjoritv of cists were resist int to phenstoin 'ts> t
of his c iscs stiffertsl from mi|or cpihps) but the drop
was ilso of use in psscliomotor sti/uris tlioiqb not in
petit mil Meibom ind pbtns tom were sometimes jnen
together with ippircnll) n ssncrtnlit clfctl pheno
birbitont ssns not used is metlioin done txirttd i
wcllmirled soporific cfftct Him nnd Otio (I9J7)
- tre ittd 20 C 1 S 1 .S of psschomotor tpdtps) ind found
tint 13 wtre rtndtrtd ittntl frtc I ttitrm in ind Weil
(1947) I Lltcrnnn ii <il (1917) nnd rcllirmin ind
VictorolT (1949) m a trnl with 150 pilienis tonsidtred
ncthoin to be birhl) ctTcctist in m ijor tpdeps) \ dti
nblc m Jacksonnn epilepsy nnd of occ iston d os'- iii
psjcbomotor ntlncls They stressed that good results
sserc ichicscd when other remedies hid filled In p"tit
mil the drug w is not of use And (19 IS) reported a
group of 75 pnlicnts resist iiu to other meisures and
found dmost complete control in more linn li df
the tiscs of nnjor pssebomotor nnd Jncksomin
epilcp,y
Although \ dinble, it soon becime nppnrcnt tint
mclhom was dso sometimes toxic ind that its use
called for the same c ireful supervision ns with troxidone
GioLs (1947) found tbit toxic rciclions de\ eloped in
10% of pnticnts while of I^cnnox s (I94f>) cises 14%
hnd a rash Kozol (1947) reported i 6% incidence of
morbilliform rnshes during the first month of tre itmcnt
but thought thnt renctions were mnde less Id cly by the
use of smnil initial doses Loscaizo (1948) si itcd that
n history of previous sensitization reactions was common
in patients developing a rash and stressed the need for
n careful history m this respect
MFN I 01 I I’ll I PS') , rrn-,,
^ ^Tl TAl lot
Orov .in'ss wa tunmmnl) lepnrlcd as a sidcrnfccl
of incilmin but f urn Inpirlroph) indatixia vhich«n
often o'-ciir dutmi phenstoin Ireitmcnt, sserc rnr-ls
'cen
Minor blond eh uu cs v ere found in IS of retterm m
ind Vietnro'I » (19.4) t ises and I ennox (1946) report d
I rclilise Ismp'nevto is m '0 of his stics Olhc
ilitlu) s often toi 111 ciit'-d on the iVvitrrcncc of n re! ti c
IsniphOk' teas nnd iho of coMnophilia ih" lattc' par
lieulirls in the p c'cnct of derm itilis
S n >iis up site I toxiw efic-ts included iphstic anarinn
ind cxfohitise ilcmitiiis In the Aniciiena Iitc iii c
ihc'c ire repsrts of six fud cites of aplastic anaemia
Old of ei Ides cs th U recovered I he reicirnns oceu red
three to cobtc n msiths ifter stulme met'iom ll cr ip)
\hhott mil Svliw h (19)0) m rcucsme the prob’em
thou lit tint se loiis hloosi cli orders were not of sudden
on<cl IS w i' held In sqm'* hut rep evented the su iden
ctdinin itis'is of i pro '•cssisc p o ess The) Ihnufhl it
pnssihle that piticiits developing i senuii/ilion dcr
iiiititis were less likcl) to siilfc a s-rious toxie cffec.
suhscqiienllv
I xfolislisi. d-imatitis IS tcpsnrted m four easts two
hem fitil (Rust III P’tx Kivol lOSO)
Ilcpitu dis'ise w IS found m two f da! c’ses one
treiicxl with nielhom hid a eentrd lobnlar ns-crosis and
one dcvc!op*d i fstd hepsto renal ssndromc fo'Uiwins
ire Itmcnt With metlioin troxidone md plrniiionc (1 ess
ft III lusii) Riiskm (19 IS) s’ltes tint methom nnd
troxidone arc hoili pitcntnll) toxic nnd tint loth arc
related to the toxic suhstnntC phcnslclhslhsdanto n
combined ii c of the drugs is th rcforc dmtcrotis
Present IiiscsIiKnlion
Cases were scl-eicd for nictho n treument onis after
other remedies hnd been proved inclTcctivc in full
lolentcd dosnie Pnticnts sulTcrini from petit nnl
were not given methom ns published results were so
uniforml) diseourni ini Alloeellicr 4] pitients we'c
tre lies), hut onlv 2) (l) femde 11 mile) were con
sidtied Miiinhic for nssessni-nt the others cither faded
to tdc the driie retululs ur omitted to keep adcqi ite
records of the numbers of their iltieVs The nveriec
me w IS no the voiingcst heme 10 venrs old
A ifctnded history w s taken in order to determine the
type of cpdcpsv iiul c-ircful reference was nnde to
previous dnq sensitivity or other form of altcrey I re it
ment vv IS iisiidly hei un with 0 1 g twice daily this
heim mere ised hv Oil a day at wecklv or foriniilitl'
intervals until the neeessary amount was hcine tiken
The number of altieks ami the tvpe were recorded
It each intciview the frequency heiiu 1 iter comp ired
with that before metlioin therapy nnd improvement
being cdculated on i percent ue basis thus
wen ' c number o f nuaeks n m onit i after irc a imcnl ^ gT
nvcrai c number n month ticfore irealment J
Some rliflicultv vv is experienced m obtaining exact
ligurcs of both mcidtnce ind type of fit as most of the
patients suffering from major epdepsv hnd "warnings
or minor psychoniolor phcnomeni, in addition to attacks
of grind md nnd tended to neglect the smaller attacks
in making llicir report Similarly patients with psvcho
motor epilepsy were not always conscious of thcir
attacks or could not be persuaded to keep a list of
them other than in thcir heads The results arc there
fore onlv approximate
Jan 13 1951
METHOIN IN TREATMENT OF EPILEPSY
BRITISH
Medical Journal
65
Table I —Results of Treatment
Case
No
Sex
and Ag
Yypc of
Epilepsy
Duntion of
Methoin
TrcTtment
(Monihs)
NTain
icnance
Dosice
(G /Day)
Result
(P rcuntace
Improve
ment)
1
F
Major
4
0 0
70
■5
h 40
7
2 1
No change
3
r 46
10
09
70
4
r >6
r
0 8
ino
F 29
9
09
90
6
M 35
09
No change
7
Nt 24
4
1 2
50
8
1 M 30
4
09
50
9
1 M 33
3
0 3
No change
10
M 25
5
1 2
60
U
r 24
Major and
7
1 1 2
70+50
psycbomoior
\2
r 48 '
8
00
50 4- no change
U
M 24 ,
4
09
50 +50
14
M24 j
2
06
No change +
no change
IS
M 19
Major and focal
5
09
100+50
sensory
16
F 45
Psydioinotof
9
06
80
17
F 27
1 5
Sf tht
18
F 41
7
09
No change
19
F 10
3
0 \
20
F 23
6
06
50
21
F ^2
9
02
100
22
M 31
7
09
95
23
M 21
10
1 2
60
24
M 26
10
09
80
Results
The results are shown in Table I The degree of
response to treatment has been divided into three
(Table 111 much improved indicating a 70% or more
reduction in the trc'^uency of attacks improved a
50-70% reduction and no change if less than a 50%
reduction
Taclc U —Do rcc of Response to Treatment
1
Much Improved j
Improved
No Change
Major epilepsy |
Psychomotor epilepsy i
40
1
33/
1 ""
27/
1 39/
It will be seen that best results were obtained with
cases of grand mil but even so they are less impressive
than most of those reported in the literature It is pos
sible that selection is to some extent the cause of this
the cases were chosen from amongst a large number of
epileptics the bulk of whom had been attending hospital
for some years Thus there had been every opportunity
for a trial of control by other means and only those
in obvious need of something better were given methoin
A further point is that a certain number of patients,
although their attacks were not fully controlled by
methoin stated that the fits were shorter m duration
and milder in degree, or that a larger proportion of
them did not progress beyond the aura stage
lUustrahvc Cases of Successful Treatment with McUioin
Cfljc 4— A woman aged 26 developed major and minor
epilepsy at ihe age of 10 There was no significant past
or family history and no abnormal signs were observed on
examination She was an unstable person much upset by
her attacks and had twice attempted suicide With pheny
torn 0 5 g a day and phenobarbitone attacks were not
controlled and she became ataxic With methoin 0 8 g a
day she was free of attacks and considerably more equable
in her behaviour
Cose 15 A man aged 19 of epileptic stock had his first
attack at the age of 6 months and by the time he was 11
years old frequent fits were occurring usually preceded by
paraesthesiae spreading up from the right leg to the right
There was a left parietal electroencephalographic
focus but air studies were normal Before methoin treat
ment he was experiencing one to three major convulsions
a week with also frequent abortive sensory attacks Pheno
barbitone 4 gr (0 26 g) with phenjtoin 6 gr (0 4 g) dailj
was ineffective and caused ataxia and severe acne With
methoin 0 9 g a day and devlro amphetamine 20 mg i
dav no further major attacks occurred and focal sensory
attacks were reduced by half His behaviour vvhich for
some years had been a,,gressive and sometimes violent was
not improved
Case 21 — A woman aged 22 first developed cpi.epsy at
Ihe age of 10 the attacks then consisting of sudden nausea
a bad smell at the back of her nose and clouded conscious
ness In later years she had had up to eit,ht attacks a
month of an epigastric aura followed by pallor semi
purposive hand movements and sometimes complete
amnesia At times attacks were followed by an mdescrib
ably bit'er taste but there were no convii'sions No abnor
mal neurolocical signs were found but there was a right
anterior temporal electroencephalographic focus Pheno
barbitone phcnytoin and troxidonc were all ineffective but
only one attack occurred after methoin was given and com
plete control has been maintained with 02 g a dav Her
eosinophil count rose to 20°' during the fourth month of
treatn ent but she was at that time suffering from a
r“curience of hay fever
Case 24 — A man aged 26 was knocked out in a boxing
match and had his first uncinate attack four weeks later
He was at that time drinking rather heavily Since then
he has conlinued to have attacks associated with a sweet
taste a sensation of dem vii and hp smacking He can
continue wor* mg or speaking during an attack but usually
checks his work afterwards to ensure that no mistake has
been made Pbenvtom could not be increased beyond 06 g
a day but with methoin 09 g a day there is almost full
control
In Cases 21 and 24 methoin exerted its effect rapidly
and it has been noticeable also in other cases of the
series that control was achieved early in those respond
mg to treatm“nt while in those failing to respond large
doses were little more effective than small
Cases Not Responding to Methoin
Cose 2 — A woman aged 40 developed epilepsy at the age
of 19 the day after her first child was born There was no
family history of epilepsy or any neurological abnormality
on examination The atlacks have not been adequately con
trolled by pheny torn or by methoin 21 g a day and the
two drills given togelher are not more effective
Case 12 — A woman developed major epilepsy when aged
21 Now at the age of 4S she has up to 12 attacks a week
and there is severe deterioration of personality Complete
investigation including air studies has shown no gross
abnorn ality Some of her present attacks are undoubtedly
hysterical though nearly all are associated with urinary
incontinence With methoin the grand mal attacks are
possibly less frequent but improvement is minimal
Case /7— This patient a woman aged 27 weighed 13 lb
(5 9 kg) at birth and was cyanosed dunng the first week of
life She developed normally however until the age of 8
when a generalized convulsion occurred Since then she
has continued to suffer occasional grand mal attacks but ■
now has mainly psychomotor episodes usually several each
day In them an epigastric aura is followed by a desire to
run away and then masticatory movements occur she may
rub her hands together and is sometimes incontinent She
cannot speak during an attack A ray examination revealed
a small calcified area in the left temporal lobe and a slow
wave electroencephalographic focus was present m the same
site Phenobarbitone phenytoin or methoin up to 1 S g
a day has not materially influenced the attack rate
Electroencephalographic Changes
Little (1949) studied the effect of methoin on the
electroencephalogram (EEG) m 26 patients In 62%
an increase in fast activity occurred and in 58% alpha
MIlllOIN IN IKLAIMIM 01 I I'll Il'S^
f’fMl H
cf.'jAN n 1911
.ictiMlv was dtcrciscci Willi conliriiicd dosui. ihcsc
cITl’cIs bccnnit more pronounced iliou[li llurt w is no
torrchlion bclivtcn the CI'Ci cit inj t' md the then
pctilic response. rcKirniin and Victoioll (|9)9) found
thill in some of their cases the nlpln lelisits hceinic
\cr\ rt!,ulir, but tlic\ likewise obsened no eorrclilion
belwe n the IZ I G pillcrn mil the tlinie il si ite I) reel
ind /iskind (1910) si iled III it nicllioin led to in iiieri. isc
in fist ictisils in the I LG iiul stressed its likeness
to the barbitur ile-s in this resp-et
In the present scries the I I Ci cbm cs were sm bed
in 18 eases In II there w is m mere ise in fist (20e's)
aelisiij, sometimes lo a ni irked cslent this did not
seem to dcp.nd on the diirition of Ircalmenl Ihoiijh It
disippeared rapidh in one cisc after wilbdnwal of
mellioin
III en,ht cises i tioiiecahle clfcet w is the dcselopmcnt
oi 1 uniform imp'ilude of all the frequencies In some
the I LG bee imc siril iiu Ij reriilar in ippear inec par
ticiilirl) so when f> c/s lelisiti w is prominent in the
record llic nndini is presum ibl\ rel ited to the tej iiI ir
alphi aclivils reparicel bs Pcllerman Ihouph in the
present scries ihis frctjiienes w is nril ilfcelid more than
others
\ deeieisc m slow wave actisits w is seen in three
CIS s ill of wbieli ilso desclopeU the inerea<eil rein
I irils of pattern
There w is no eorrclation between the 1 I G ebintes
and the clinic il state This confirms pres ions reports
but IS none the less surprisuij in sicw of the decree of
chince sometimes produeed bs mcthoin I he effect of
barbitiirites is to some extent eompirible in thii fast
actisitj m IS occur dunne Iq lit sedition hut mis ilso
persist durinj. conn from barbiturate poisonmr I'os
stbls methoin ind the barbitunies base this effcst in
common because of their related chemieal structure is
Bercel and Zisl ind siq i est but it se ms th it the cb inpes
are not related to their tberipeutic elfcet
*9
IMethoiii loMclts
In order to iserl toxic re iclions so far as possible
methoin ssas started in sm ill doses (0 1 ( tssice dills)
and griduill> mere iscd sshiKI prtsioiislj iidministcred
drugs sserc progrcssiselj ssiihlield Plienobirbilonc
hosvescr ssas usualls stopped (|iiickls owing to the
soporific elfcet of methoin
A strict system of control ss is used regulir blood
counts ind visits being enforced b> gisiiq onij a limned
siippl} of libicts Patients ssere told to bessare of sore
thro Us feser skin rishes, m il use ind spontaneous
bruising I hc> svere instructed to report anj such ill
clfccts at once
Milr/ Toxic C0ecl\ — In b3% of the eases the patients
complained of drosvsiness svhich in some continued
throughout the period of trcitment In the m ijority
small doses of dextro mipbetaminc controlled the symp
tom fully Other complaints were dizziness indiccstion
headache constipition frigidity ind gam in weight
The last named occurred m tivo female patients to ii
quite marked degree Gum hypertrophy and itaxia—
commonly occurring with phenytoin— -were not seen
One patient h id had acne before treatment svith methoin
and this became worse A relative lymphocytbsis with
or without cosmophilia occiiircd in eight piiicnis and
It may be of some sigmficanee that four of these gave
a history of some form of allergic reaction m the past
Iiri/i lltitiiiiitn — An leiilc febrile rcaelion wilh mor
hilliform risli o eiirreal in five pili nis (21 ) -two
occurred duriiij the first weef of ircumcni two in the
first month, ind one m tlie fourth month One of thrve
hid hiitl in iiltiek of tirlicarn in childhond one hul
bid tnf mtiU ccJ'cmi mil ahn develop d a r I'li with
phcnyloin thiil not wuh troxidonc) and one develop d
I rtsh with iroMilone two did not [ive n liuiorv of
prcviouv scnvilivity two piticnlv noi included in the
scries il'o dcvclop-d rashes one had had nctllcrash
once as 1 ebild and the other Ind suffered from
U ijniiid s disc ISC of the linecrs
Il does >ccm the cforc tli it patients with a hiUnrv ol
previous srnsituitv should (c obverved elo'clj for a
simil ir re prmvc to nitthom pulicuhrlv durmt tbccirlv
weets ol tteiimcm In all these patients mcthoin "is
tempor iril) stopped, hul was pradinlH resumed with
out til cffcet except III the e isc repo. led below
Severe {{rirthmv
I here weic llircr severe rcielionv one Icrniiinting
fit ills
Cur tv — Tlilv patirial jiiffered from frequent and vvere
pUeliimio or ilnck> and hul fad d In revpeu’d to troviJoa;
or lo phca)iori \Siih ihc Ijller d up a severe e'ernea Mis
proptevvinp niniovt lo rvfohvlion (s,.euricd and w„v vtdl
evident when n clliom w is vl iried in «a ill doses Tt-
rash revolved ssinf.clorib, hni mclhoin c'lilj nol be
lonlimi-d owing lo a propresvive ilcgfc of leu open a
Another piticnl (nol ii vliid'd in die senes) was la) lip
12 I of niclhom a day in hiv fourth monih of ire-'intn
when he compliincd of nnlitve and fili,iie The cervical
Ivniph nod s wire cnlargrd and there "as a p-tcvhnl crop
Ifon over Ihe slioiik'erv Die real blood cell an I p'lle! I
counts were nornnl hul llierc aov i relative Ivmphiv-yiosis
of IS After iiielhoin tnd le-n stopped the rash subsided
and die hlooil piclurc Kkaiiic iiorniaf
( asf 16 s
A vvomm ajed ep first had epilepsy ii puberty with atlicks
rcvcnibhni fainl After sever il scars dnirn il and nociiimal
prand nul developed bid b'c mae infrequent dtirm., ific hvi
five years when her mam complaint was of ilistrcsvinc
pvychoinotor macks occurring in senes She had no si,,niri
cant pisl history hul dicre wav i hiviory of cpilepvv in die
familv Nciiroloiual cx iiiainalion revealed no ihnormahlv
On October 26 ft lb mcthoin 02 g daih was viarlfJ
blit the palicnl slopped taking the lablcls four days later
ficcuise of a dazed feclinc, this hemp followed m two davs
by naal live and a morbillifi'raa rash On November 9 the
driip vvav resumed and was pndiially increased lo 06 g a
day This dosaic controlled her iltacks well ind ssidiotil ill
elfcet except for ilrovssmess sshich responded lo dextro
implicl inline
On Jaiuiiry II 1910 die pilicnl ss is sstll but complained
of II gun in Weight On Marcli It slic compliined of sore
ness inside Ihe moulh but there was no apparent iikcrilion
mil the blood coiml w is normal
When seen on June 26 she was qmlc well but on the
night of June 30 she complained of ulceration of the mouth
and diflicully m sw diossmg The next diy n blood cotinl
It another hospital rescaled 700 vshite cells per c nun all
bcinc Iviaapliocytcs Slie was admillcd lo dial bospiial and
cxamin ilion showed haemorrhagic iilceraiion of the gums
bruising on the limbs and n posilive loiirni piel lesi 1 resh
blood Ir insfiisions penicillin mil aurcoincm were
given mrl die coiiclMion of her moulh laaproveel I aler
hovsever severe menorrlngia and a higli kmpcratnre
developed these continuing until her dcidi on July 9
Serial blood examinations revelled a persisimg complete
agranideieytosis with seintv oi abvent blood plilctels
Jan 13 1951
METHOIN IN TREATMENT OF EPILEPSY
Brntsu
Mancjo. Journal
67
At necropsy the bone marrow \ as found to be aplastic
There were generalized \isceral pctechiae and also a recent
basal subarachnoid haemorrhage
It IS not known exactly when the blood picture in this
case became abnormal, as the illness began svhen the
monthly blood count was due Previous examination
had not shown any abnormality m particular no lympho
cytosis or eosmophiha When the patient was admitted,
however the granulocytopenia was already severe 'She
therefore developed a fatal aplastic anaemia eight months
after starting methoin therapy The symptoms were
rapid in onset though it is possible that significant blood
changes would have been recognized had more frequent
examinations been earned out There are however
practical limits to this procedure
Abbott and Schwab (1950) suggested that serious toxic
effects were perhaps less likely to occur in patients
developing a hypersensitive reaction early in the course
of treatment, but such was not so in this case It has
also been maintained (though not specifically with
methoin) that regular blood examinations are fruitless
that by the time changes are evident m the peripheral
blood It IS probably too late to attempt treatment An
alternative supposition is that blood dyscrasias are of
sudden onset and therefore not subject to discovery by
regular counts Abbott and Schwab discounted this
however, and the safest course must remain that of
examining the blood as regularly as possible during
treatment
Discussion
As has happened with other new preparations in
recent years, methoin proves to be a valuable but some-
times toxic drug This study confirms its usefulness in
major and also in psychomotor epilepsy and shows that
dramatic results may sometimes be obtained It is, how-
ever a drug of definite toxicity, and its use may be fatal
Clearly methom should be used only when every
attempt to obtain control by other means has faded
As beneficial effects usually appear quickly it is better
not to persist with it in patients who are resistant , on
the other hand a short therapeutic trial may be made
with little danger
If methoin is used certain precautions must be routine
(1) Instruction of the patient and relatives on its pos-
sible dangers, with the warning that they must report
any suspicious symptoms at once The patients own
doctor ought also to be notified that the drug is in use
(2) It should not be used in conjunction with other drugs
likely to cause similar reactions It should not be used
with troxidone though a number of resistant cases seem
to demand this very combination (3) The patient must
be seen and blood examinations earned out regularly
throughout the period of treatment
Summary
The results of methoin treatment in 24 cases of major
and psychomotor epilepsy are described A reduction of
70% or more in fits occurred in 40% of major epilepsy
cases and m 31% of patients with psychomotor epilepsy
Details of EEG changes due to the drug are given
Toxic effects including a fatal aplastic anaemia in one
case are described
The value and limitations of methoin are discussed
ft IS a pleasure to record the help of Dr Denis Hill ai whose
suggestion the Inal was undertaken 1 am also indebted to
Dr T V Mendelsohn for his detailed report oa the fatal case
C
and to the Department of Clinical Prlhology at the Maudsley
Hospital for carrying out ihe large number of routine blood tests
r
RcFCPCNCES
Abbott 3 A and Schwab R S (1950) Nch Engl J Med
242 943
And R B (1948) Cahf Med 68 141
Bcrccl N A and Ziskmd E (1950) ElecJrDcnceph & elm
Neuropil} slol 2 222
Boiler W (1943) Schlveu rned lEsc/ir 73 699
FeUerman j L Friedman M D Weil A A and Xhetoroff
V M (1947) Ohio St med J 43 1251
and Victoroff V M (1949) Ots rreri S}st 10 355
and Well A A (1947) Med elm N Amer mi
Gibbs F A (1947) Ann intern Med 27 548
Harris T H and Olto J L (1947) Tex Si 1 Med 43 328
Kozol H L (1946) Amer J Ps}clual 103 154
(1947) Ass Res nerv ment Dis Proc 26 404
(1950) Arch Neurol Psychtat Chtcaio 63 235
Lennox W G (1946) Amer 3 Psycbiat t03 159
Levy R W Simons D J and Aronson sS (1950) New Engl
3 Med 242 933
Little S C (1949) Electroeneeph iS elm Neiirophysiol I 325
Loscalro A E (I94S) J neri went Dis lOI 537
-* — (1946) Amer 3 Psychtat 103 157
(1947) 3 Amer med Ass 135 496
(1948) Ibid 138 1114
Ruskm D B (1948) Ibid 137 103 1
TUBERCULOSIS IN KENYA
BY
W S HAYNES, MA. M D
Medical Officer Colonial Medical SerMce, Ken\a
t
I
Details of the Survey
A tuberculosis survey of Kenya Colons was made
between February, 1948, and February, 1949 In
default of mass miniature radiography the method of
the survey was limited to tuberculin testing physical
examination and the examination of sputa It was
possible to get only a single specimen of sputum from
each suspect the likeliest looking part of which was
smeared on a slide, dried, and subsequently examined
at the Government Laboratory in Nairobi by the Zielil
Neelsen method The usual methods of physical exam
■nation were employed, but care was taken to exclude
all cases except those with definite and persistent signs
Unequivocal signs of cavitation were taken as a proof
of tuberculosis bronchial breath sounds and post
tussic crepitations were, unless there was evidence of
recent acute infection, classified as suspicious of the
disease
Although limited m method the survey was of con
siderable extent Africans were examined at 34 differ
ent places chosen as giving a fair sample of the more
populous parts of the colony In all, 49 812 mtra
dermal injections of 0 1 ml of 1 in I 000 old tuberculin
were given, and a reading was obtained 48 hours later
in 42,492 instances An indurated area more than
5 mm in diameter palpable 48 hours after the injection,
was taken as constituting a positive reaction A total
of 2 889 physical examinations were made, and 1,298
specimens of sputum were examined for tubercle bacilli
Control Senes
Some attempt was made to rule out non specific ,
allergy to old tuberculin which might be supposed to ^
occur m the African, prone as he is to helminth and
protozoal infections Ninety eight hospital patients
were given an mtradermal injection of 0 1 ml of 5%
MtOicn Jtn 0 f,n
6S II, 1951 rUDLRCULOSli IN KCN^A
{,l\L<.rin broih los,cllitr \Mtli Iht NHiUoux («t I ifty
four rcicictl to the tiihtrculin anil one of l!i m \Uio<l
M iiMoiiN test ivsiiltcti in blistcrme re letej to the con
trol solution with nhit ippeireil to be t tjpicil tuber
culm re letion I itcr, S9 sehool children ocrc tested
with old lubeteubn 'tiul it the vime lime oilh m ecimvi-
lent dose of I* 1> O (I’lrk Disis ind Co I I ort> eiilit
horns liter 46 showed i re letion to the old ttibeieiihn
ind “iO to the I’ I’ I) solution
Oeeiilt lepros\ Ins been sin ested iis ii possible cuisc
of r ilsL positive liibcieiilm rcietions (d Are) llirl
1942) In 1 tceent survc) of the colon) Ross tones
(19 IS) found in iver u e incidence of 10 lepers per 1,000
of the popiil ition However his liriires bevr no tcli
tion to the tuberculin sensitiv it) rates of the ■ ime dis
triets \ sni ill leper colon) it Msimhvvcni on the
coist, eontiins '4 c i es of f ir idv meed lepios) Ihcse
were tulKreulm tested ind 29 rcielors were found o'
St 4' T eonip inbL ipc i roup ot 9)9 of the t-enet 1
popiil ition of Msimhvvcni rvvc 74s or 62**''^ rcictors
Of the five non re ictors two vverc f vr ids meed lepto
mitous e ises ind three hid tuberculoid leprosv
fills sniih control senes siiRecsts tfiit the tenenf
results obt lined ire not si; nificinti) ilfccted b) non
sp'cific reictions (o tuberculin
Tuberculin Sensltlvilv Kites
The results of the siirve) ire shown in rabies I and H
I ible III sliowi the low scnsitisit) rites found by
Riirrows (1935) amoni the southern Sudanese of the
II ilir el Ohti/ il province It is here tli it I )lc Cummins
(1949) in 1902 found no evidence of liibcrculosis
' amonp the mtiscs cittle ind wild panic
M lelcnmns (19351 hriires for I’dcstinnn Atabj are
i|so consider ibl) lower th iii those of the kcn)a sursc)
He tested II 403 u ban ‘ehool children of 5-13 years
of ipc ind found I 923 or 16 2 rcictcd to I m I 000
old tubcreiilin Of 4 u60 rut tl 'ehool children tS4 ot
13 2 rfiilcd Tile hviircs for children of the 7-12
>e irs ipe pronp in kcn)i ire 37 5 and 22 1 , respee
tivcl) (1 ihles I md II list column)
On the other bind i recent siirscs of th- Gsdd Coist
h) lodd (19 tS) showed no sirtm ircis but Inth rites
of tiihcreiilinir ition it ill ipes , tests with rising
sttcnplln showed n“iiK 100 positive b) adult age
Hie Soiilb Africm Mines Report (1942 pp 209 206)
showed tint 72’' of recruits who cime Itoni sirious
nviivc territories reietcd to I in 5 000 old tubTeuhn
on cm i-cmcnt it the mines, mil ‘ repcited tests with
ttronpe: diliitiois would prvsbiblv (isc 90', teictors
In rnplmd the I’topfut Sursc) ff9f5l records t/nf
the )oiini idiill popiihtion stii lied shows an incidence
of tubcreiilm seniiii?ition of the order of S5‘'', for main
and f'2'u to 94'' fo- (cmilcs In kens i the
19-25 )cirs eroiip of nibm residence w is 54 7'^ for
men and 63 4'y lor women (Tihle 1)
TaiiI I I — Tiihercntiii Sensiii\ ii\ hntes hi S 1 42 Afrit an Main a’ it 947 African f ft < Vr AVi tc it in \(f>nit ri i an 1 Si rohi
/ cii\a (Ma\ ri i! Uicenit cr I94S \Iiu nuit J m / r^O) LfrlniAnifj
Ar Orcun j
1 Malei 1
le ut t
1
' n 1, VI I
So
Te tevJ
1 UtJ
Ur\ 1
^ >
TritfO
1 HfJ
V'* 1
1 Icli
rod j
1
K'n
1 b' !
1
1 t i
Nfl 1
UfHj f I i
2S
0 1
0
•4
1
(1 > 1
> 1
.1
(1
UJ
(If
7 1
< 0
10)
8
^ 1
'14
7 0
4-0
143
''0 !
14 0
1 4
20
\r 1
-A-’
40 ;
MU
7-U 1
IW 1
4 1
157
MO
416 j
1<6
1 37 <
13-18
-•95
l>rj
t-O
"'O
{4'4>
' \
1
19-25 1
705
i
8^7
tnn
nv j
n )
> <^3 j
V> 1
1 ^ 4
1 <V7
1
>9 4
20- 1
7tj 9 1
111
1 "'i !
! '7 3
41-
^ 4
If
11
{ A4 M
«41 1
1 A 0 1
1 3'^ 1
Mi ni c^
3 13.
1 ^ i
75 7
937
41S 1
STS 1
4 O '> 1
1 1
l::!! J
! 6>-
i
Tmilc II — TiiherciiUn Sensiii\ll\ Rates hi 17 07S African Stales anil 16 317 African rcnialcs hesufent m S'aliie Resemes
Kcrmatl ehruar\ 1947 to f ebruars 1949 Sfuntaiix I in I 000) Rural Rates >
Ale Group
Malci
:inni
1 emnlci
Unh S:
No
Tc5tcd
Hn
No
TeMwl
1 ««< rs
1 il
Ic \cd
UcJ ikirs^
No
Vo 1
So
Under 1
4-1
lu
2*4
4(6
7
1 5
fe7v)
17
! 9
1-3
1 418
73
5 2
1 313
f-
4 5
: voi
U5
4 S
4-6
1 527
176
II 5
1 5-6
:i5
14 1
luM
391
1 S
7-12
3 J )6
B74
21 9
731
23 -
7 Ml
1 605
13-18
3 212
1 3J2
41 3
1 (H»2
37 6
5S75
2
40 7
19 25
1 003
7U6
70 4
10 2
51 f
2 >54
1 7 h
57 8
26-40
2 f38
2
«1 5
1 95\
5> >
5 s 6
A ItV)
(9 6
41-
2 hoO
2 345
h"* 1
1 1(3
61 8
4 741
3 <05»
74 2
All acc7
17 078
7 725
45
16 313
# Ml
J7 7
1} VDI
ns7s
41 6
There is a close simihrity between these results and
those recorded by WilcpcKs (1938 p44) who nndc a
somewhat similar survey of Tinginyiki fifteen years
I ago His mmy tables cannot be reproduced here The
Kenva rates are rather higher except for the younger
age groups This rs also the main difi’ercncc between
the Kenya findings and those of Matthews (19354 who
made a survey of Zanzibar Comparison is difficuU in
this case beiause of the more complicated technique he
Used
The kcn)a sursc) demonstrates (he marked differ
chcc in rcictor ntes between males and females and
between those living m town and those in country dis
tticts Kenya m common with other colonics suffers
from a hek of vitil statistics, and there arc no figures
of the tuberculosis incidence in the dillcrcnt pirts of
the colony 11 docs seem likcl) however tint the
tijbcrciilosis attack rate is higher in the tovvns or at
Itiast in the two largest, Nairobi and Monibisa, than
lb most country districts ^
I
Jan 13, 1951
TUBERCULOSIS IN KENYA
BRmsn
Mcdical Journal
69
Table III — Tuberculin Sensilniiy Rates (Burrov-s 1935) in 2 369 Sudanese Males and 1293 Sudanese Females Resident
111 Balir el Ctiazal Proxince (Old Tuberculin I in 500)
Age Group
[ Males
I Females
1 Both 5,.xes
No
Tested
1 Reactors
1
No
Tested
1 Reactors
No
Tested
j Reactors
1 No
1 /
No
/
No
/
0-5
201
18
90
225
14
60
426
32
7 5
5 10
^85
125
, 21 4
261
41
157
846
166
19 6
10-^5
973
367
1 37 7
475
156
32 8
1 448
523
36 1
Over 2^
610
342
56 1
332
136
41 0
942
478
507 ^
All as s
2 369
852
36 0
1 293
347
26 8
3 662
1 199
32 7
Men often woik for a spell m the towns and 'return
to their wives in the Reserves when they have earned
a little money When adult males were tested in the
Reserves they were asked if they had ever worked in
Nairobi or Mombasa of the 5 Q07 men tested 3,029
who answered Yes showed an 83 1% reactor rate,
while those who answered No gave a 72 3% reactor
rate
Disease Incidence
It vvas not practicable to examine more than a small
proportion of tuberculin reactors An attempt was
made to examine all those with chest complaints child
ren who reacted and their contacts, and contacts of
suspected cases of the disease, and also to collect a
specimen of sputum from these people So besides the
cases missed by physical examination — which, having
regard to the type of disease the African gets and the
ease with which the tubercle bacillus is recovered from
his sputum may be fewer than would be expected in
European practice — it is probable that some cases of
tuberculosis escaped examination altogether
It was found necessary to divide those diagnosed as
tuberculous into proved ’ and suspected ’ cate
gories according to the criteria already described The
number falling into (he former group for all the places
surveyed averaged 4 6 per 1 000 It is felt that a closer
approximation of the true state of affairs would be
reached if both proved and suspected cases are
combined in which case the average incidence amounts
to 11 1 per 1 000 The 1948 census gives an African
population of 5 252,753 If we take the incidence of
only proved ’ cases found during the survey as an
average for the whole colony, then there are 24 000
cases of tuberculosis in Kenya The figure of 1 1 1 per
I 000 gives a total of 58 000 cases of tuberculosis and
It IS felt that this IS more likely to approximate to the
true number
It IS interesting to find that Wilcocks estimated the
incidence in Tanganyika as 1 1 55 per 1 000 In Southern
Sudan Burrows diagnosed tuberculosis in 173 cases,
which m an estimated population of 156,300 gives an
incidence of 11 1 per 1,000 In Palestine, MacLennan
estimated the incidence at 5 per 1,000
It must be made clear that the Kenya estimate is
based on the number of cases actually diagnosed among
the general population examined in the native Reserves
No account is taken of the few cases lying in the native
hospitals of the colony Hospital figures give no indica
tion of the incidence of the disease Although cases of
bone joint and glandular tuberculosis were seen fairly
commonly, there is no doubt that pulmonary tuber
culosis IS by far the most prevalent and most important
manifestation of the disease in Kenya
As can be seen from Tables I and II, for the purpose
of tabulation the sexes are divided and each sex is classi
fied into eight age groups In comparing the reactor
rates found in dilferent districts it is necessary to select
one age group Adult males are often used but as has
been shown, their reactor rate varies with their experi
ence of the towns Children in the 7-12 years of age
group have been chosen here ' Large numbers were
tested Sexual differentiation in tuberculin sensitivity
rates, at least is not marked and males and females
may for this purpose be combined Their peripatetic
habits are free but local, and when they become infected
they probably do so within their own district Table IV
compares the sensitivity rates of this age group by dis
tncts Tests which were made at various places within
the same district and tribal area have been combined
The disease incidence, computed on proved and
suspected cases found in the whole sample of popu
lation tested for the corresponding districts, is also
shown
Table IV — Incidence of Tuberculosis per I 000 I Pro\ ed and
Suspecied Cases) in Both Sexes and at All Apes Related
to Tuberculin Sensiintty in Boili Sexes at Ages 7-12 Years
District
Both Sexes 7
-12 Years
Both Sexes
All Ages
No Tested
/ Reactors
Tuberculosis
Rate(pcrl 000)
Nairobi and Mombasa
Urban Rales
416
37 5
—
Kapkafet(Kip’ugis)
Rural Riites
328
73
155
Mben and Ciamberi
568
96
8 5
Kisii (S Nyanza) y
582
10 1
5 9
Embu
1 119
16 3
6 1
Siaya (C Nyanza)
330
164 1
77
Maragoli fN Nyanza)
188
166
95
Kaliado (Masaj)
239
184
II 6
Kangundu (Maebako s)
725
22 I
14 3
Kenigoya
697
2^ 5
89
Teiia
532
29 9
84
Foit Hall
87
35 8
Taveta
105
36 2
16 0
Likoni Kisaunj and Cham
gamwe
367
36 4
8 0
Msambweni
237
I 39 1
9 7
Kiiui
714
1 39 8
23 5
All rural areas
7 151
22 4
11 1
It will be seen that the highest percentage of reactors
(39 8%) occurs in Kitui The Kitui Reserve is dry and
infertile (typical groundnut country), and the Wakamba
livmg there are in a miserable state of poverty They
suffer from endemic malaria, schistosomiasis, and
helnunth infestauon They seem to be dirtier and to
have a greater incidence of scabies than other Africans
met with on the survey The greatest number of
proved and suspected ’ cases ,(23 5 per 1 000) vvas
diagnosed here
After Kitui the highest reactor rates were found at
Msambweni, 35 miles south of Mombasa, and at
Likoni Kisauni and Chamgamwe all on the coast in
the neighbourhood of Mombasa In these places a com-
paratively low disease incidence rate of 9 7 and 8 0 per
y
70 Jan 13, 195: TUHI RCULOSIS IN KCNVA
1,000 rcspcclisclj wis founil NcM comi. the colony a
two principil towns, Nniiobi mil Month isi lor
vinous rcisons, no cstimitc of disctvc met lence wia
possible here Africans living in the towns arc usinlly
at work ind if the) fill sitl either go to hosp t il or,
in the CISC of pulnion ir> tiibtrculosis more often return
to their UeservLS I bus dihouth it is Id th tint tuber
culosis often develops in the tirbinired African it is
not expected tint i verj huh divcise incii'cncc would
be found except inioiif the indigenous popu’ ition
M ileocks (1932) found tint reictor rites and diveise
ineidence in 1 iiieinviki \ tried in direct propirtion ind
tint the forniir could be tilen is i me isurc of the
litter Ibis gencnh/ition is pirtidlj true of Keiiyi
Obvious discrepincics ire the low sensitivitj rites but
rclitivelv liigh discise incideni.c found it Kipkitet
Mberi, ind Ci inibcri— ill remote and rither ivolited
up countrv ire is while the co ist d districts isexeipli
(led b\ Msimbvvcni 1 d oni Kisiuni and Clnmj imwc,
show the reverse tenJcncv with verj hi[ h re letor rites
and eonip ir itivcl} low discise incidence It is *iii rsted
th It the (irst phcnoni'-non deno es i recent introduction
of tuberculosis while the second indicites a more pro
longed exposure to the discise
Tvpe of 1 ulicreiilosis Seen In the Afrlcin
Most obseners ire nj reed tint Africms suffer from
1 more icutc ind f itil t>pc of tubereiilosis linn
luropeins Thus \ ini (1937) in in indvsis of 1(100
consecutiv,. nevropsics in N iirobi found tiibcrcii’ovis
to b> the c iiise of dc itli in 132 c ises ‘T h* post ti ortem
findings atw those of i low septic leriii i reseiiibhrii leiiic
jmlnr> tuberculosis in Curop-in children while
Wileocks (I93S p 52) finds i prepondernnee of ciscs
of icutc gdlopinr consumption These miivcs he
midvva> between the completely primitive rices ind our
rchlively rcsisliiu selves Mine workers on the Kind
were found to develop an acute form of pumonrj
tuberculosis ch ir iclerizcd b) gl indulir involvement inJ
milnrv dissemin ilion (South African Min s Keport
1932, p 25S) Post mortem evidence from Mu leo Ill's
pitil Ugiildi le ids Davies (1947 1 ) to suppose 111 it
pulmoniry tuberculosis as met with m Ug indi is
rarely of the adult reinfection t>pc but in the v isl
majority of cases is the result of primary infection Icid
ing to the development of a glion focus ind this does
not heal but leads to dissemination of the infection with
resulting death
Gclfand (1944) writing of the Southern Rhodesim
native siys he has never seen an African recover from
pulmonary tuberculosis and D ivies (1947b) quotes
Trowcll as having in equally depressing experience in
Uganda Oswald (1946) hid the opportunity of study
mg the disease in 416 Africans who developed pulmon
‘ ary tuberculosis while serving in the Army in the Mcdi
terrancan area Forty seven cases which came to
necropsy had a history of illness for an average of 5 4
months He describes the usual destructive caseous
pneumonic lesions and found glandular cn'argcmcnt
m 96% of these cases Caseation was present in 66%
and in 92% the mediastinal glands were involved
The contrary opinion, that a chronic form of pulmon
ary tuberculosis is not rare in Africans is less usually
expressed but Wilson (1928) believed it true of Kenya,
and Burrows (1935) of the Sudan Fennel (I932i writes
of cases in the Biitterworth area of South Africa
Many were fairly chronic lasting at least three years
PtmiH
MrmcjiL I'M fN t
and over, showing that the natives, under their own
conditions hid a considerable power of resistance
Allan (1932) whomidcnn cviciisivc survev of the native
Reserves in South Africa found that most of the cases
With pulmon It) tuberculosis were more or less
chronic
It will be noticed that pathologists basing their
opinion on necropsy reports, arc igrecil on the extreme
iciitcncsv and short duration of pulttioriary tuberculosis
in Afric ins Clinici ins and held vvor) ers tend to be less
p-svimistic and some believe that the consumptive
African may survive some years under the condiliuns
he IS used to TTic difierencc is to b- explained bv the
extreme degree of selection in the material avaihbl to
the pathologists Cases of pulmoniry tiibcrculovis arc
not popular in overcrowded native liovp l iK, ficililics
for ifcilint them arc not usuallv avail ibe and proper
acconiniod ilion is lacking Die sicl Afru-an iv iinvvill
ing to spend long periods in liovpiial cspectdly when
no nctisc ireitmcnt is being cirricd out ind he fc Is
little hrnrfil to his h'-alih 1 or this reason only Iho c
pidnioiiity tiih''rciiIosis subject' who arc too ill to be
thscliaiged or to drat, tbemvclvcs from hospit il arc 1 kcly
to die Oicrc Sui.)i cases comp isc the post mo tern
niiterial of the pathologists
During the Kenya stirs cy a definite history was
obtained from 70 of the 106 prosed cases of pj'mon
iry tuberculosis diagnosed No great reliance can be
pi iced on this but the as crate duration of the disease
was given ns 19 months In four cases some ptou' of
the Icnith of history was forthcoming for these ri'n
bill been disebarjed from hospitals ns proved cases of
pulmoniry tiibcrculovis TTicir lustorivs sscrc of 53,
525 IS and 37 months
TTic scry fict tbit infection ns demonstrated by the
tuberculin test is so wul-vprcad woii'd seem to faviur
(he existence of it least some chronic infect out perambu
latory ciscs For bow could the mijorits of the popu
hlion be infected by those iciiIc pnciimoaic ciscs
prostritcd by lox icmia and dying iftcr a fevs montlis
which the patholoeists describe
TTic f icl til It cases of pneumonic plitliisis do so badly
vsith collapse therapy would also seem to indicate that
such cases arc not vvilboiil exception For Disics (1946)
after 20 years svork at Kibonqoto m Tanganvika
reports in cncoiinging survisal rate in 560 cases of
pulmonary lubcrculosis treated ssitli artificial pneiimo
thorax and aneilliry mcisurcs 12% alisc after 3 years
and 22% after 10
Tlicsc obscrsations sliovs that the fulminating type of
disease ilcscribcd by the pathologists as resemb ing
progrcssisc primiry infection is not without exception
Anyone who his had experience of tuberculosis in Fast
Africa would agree that its usual course is much shorter
and more acute than that seen in Furopcan practice
The Kenya survey and indeed every tuberculin test
iijg survey made in Africa in recent vears shovvsDaviess
(1947a) assertion that the African never recovers from
Ills primary tuberculous infection to be wrong The
maiority of adult Africms have been infected and show
no evidence of the disease So fir as this factor is con
cerned the state of affairs is like that in Furopc How-
ever It IS prob ible that adult primary infection not
infrequently Ic ids to progressive tuberculosis in Africans
when they arc exposed to a tuberculous cnvironnunt
Stotts (1950) investigation at Nakuru giol where tiibLi
culosis IS rife shows that an undue mortality falls on
Jan 13, 1951
TUBERCULOSIS IN KENYA
Britisu
Midical Journal
71
Ihe small group who enter the gaol tuberculin negative
It IS Iihely that uninfected adult Africans, coming from
their reserves to work in the towns, also are hable to
develop progfessive primary disease
In view of the high tuberculin sensitivity rates found
<■ all over the colony, it hardly seems possible to explain
the extremely severe and fatal type of tuberculosis which
IS most commonly seen solely m terms of adult pro
gressive primary tuberculosis, although” this might m
part account for the observation that tuberculosis in
Africa tends to be more severe in the towns than m the
reserves i
It IS usually supposed that the chronic fibre caseous
type of disease commonly seen in Europe results from
a partial immunity conferred by childhood mfection
Many children have been found to be tuberculin sensi
live in Kenya, but only a few adults develop the chronic
apical disease of Europe It would seem that a healed
primary infection may not have the same immunizing
power in the African as is usually ascribed to it in the
case of the European This contention is supported by
the findings of the South African Mines Report (1932,
p 97) on tuberculosis among African gold miners on
the Rand These Africans were graded into four cate
gories on engagement at the mines, according to their
reactions to serial tuberculin tests — positive plus,
ordinary positive, weakly positive and negative ’
I reactors It was subsequently found that the incidence
of tuberculosis was 2 9 per 1,000 for negative
reactors, 4 5 per 1 000 for weakly positive,’ 6 5 per
1 000 for ordinary positive, ’ and 10 3 per 1,000 for
positive plus reactors In South Africa Professor
Lyle Cummins (1932) found that ‘ fully 50% of healthy
natives arriving at Johannesburg were capable of react-
ing to 1 in 1 000 000 tuberculin dilution, whereas m
tests carried out by me on clinically non tuberculous
adults in Wales only 25 % were found to react posiUvely
to a dilution of 1 m 100 000 In Kenya serial tuber-
culin testing was not done but of 37 460 Mantoux tests
made on the general population 1,969 showed vesicula-
tion — that is, 5 3% of the total tested and II 8% of all
reactors In England dArcy Hart (1932) found less
than 1% of the total tested and 2 3% of the positive
results vesiculated Wilcocks (1938, p 31) found that
in Tanganyika comparable percentage were 3 2%
and 6 1 %
It does appear therefore that Africans are more
sensitive to tuberculin than are Europeans, and it seems
likely that this factor is associated with the distmcUve
type of disease they are liable to get
If the same significance attaches to the tuberculin
' test in Africans as it does in Europeans— and there is
no reason for believing otherwise — then it seems that
both races are able to sustain a primary infection almost
equally Well This observation is of fundamental
importance for racial immunity is usually thought
to condition this ability May it not be rather that
racial immumty is a reflection of the power, not of
sustaining the primary infection but to form antibodies
to the invader and so modify an aftercoming infection ’
It IS not pertinent to this thesis whether the infection be
endogenous or exogenous
The African when infected develops a high degree
of allergy to tuberculo protein as demonstrated by his
extreme sensitivity to tuberculin but little concomitant
immunity as exemplified by the acute infantile type of
disease to which he is prone The hyperallergic state
renders him hable to an acute and destructive type of
tuberculosis on reinfection, while lack of immunity
deprives him of the power of confining the lesion, as in
European phthisis but leaves a secondary infection
unmodified except by purely allergic factors so that it
often assumes the characteristics which we arg accus
tomeck to attribute to progressive primary disease m
Europeans
Summary
A description is given of a tuberculin testing survey in
Kenya ,
A small control series did not show any significant
tendency for non specific Tactors to interfere with the
results
The sensitivity rates were found to be high in Kenya
and are compared with those of other surveys ^
A greater percentage of men than women were found to
be sensitive to tuberculin Urban residence was associated
with an increased sensitivity rate
The disease incidence is thought to be about 1 1 cases per
1 000 If this IS correct there are 58 000 cases of tubercu-
losis outside the hospitals m Kenya
A degree of correlation is demonstrated between the
reactor rate and the disease incidence in the various districts
surveyed Exceptions are discussed
Reasons are given for supposing that although the acute
fulminating type of tuberculosis resembling a progressive
primary infection is undoubtedly very common in Kenya
It IS not without exception especially in the rural areas
An attempt is made to correlate high tuberculin allergy
with the African type of pulm6nary tuberculosis
I am indebted to the Director of Medics)! Services Kenya
Colony tor permission to publish this precis of my report to him
on a tuberculosis suney of that colony
' References
Allan P (1932) Piibl S Afr hut med Res S 247 ,
Burrows Sydney M (1935) Tubercle 16 Suppl P 20
Cummins S Lyle (1932) PubI S Afr Inst nied Res 5 260
(1939) Prinutne Tuberculosis London
Davies H N (1946) E Afr med 7 23 194
Davies 3 N P (1947a) Ibid 24 357 358
(1947b) Ibid 24 180
Fennel (1932) Publ S Afr Inst ' med Res 5 209
Gelfand M (1944) The Sick African p 184 Capetown
Hart P dArcy (1932) The Value of Tubcrculm Tests in
Man p 14 Spec Rep Ser med Res Coun Loud
No 164 , '
Innes J Ross (1948) Unpublished Report No 7 to the Director
of Medical Services Kenya December 7
MacLennan N M (1935) Tuberculosis in Palesime p 22
Palestine Government Pub July 20
Matthews R J (1935) Tubercle 16 Suppl p 64
Oswald N C (1946) Thorax 1 100
Prophit Survey (1948) Tuberculosis in Youne Adults p 30
Report on Prophit Tuberculosis Survey 1935-44 London
South African Mines Report (1932) Publ S Afr Inst med Res
S
Stolt H (1950) E Afr med J 27 379
Todd K W (1948) Tubercle 29 200
Vint F W (1937) E Afr med J 13 332
Wilcocks Charles (1932) Ibid 9 88
(1938) Tuberculosis in Tanganyika Territory Government
Printer Dar es Salaam
Wilson C J (1928) E Afr med J 4 296
During the period October 15 to November 6 1950 570
U S Navy medical reserve officers arrived at Brooke Army
Medical Centre San Antonio Texas for assignment to
active duty with the Army These officers were interviewed
by a staff officer from the office of the Surgeon General
for professional classification and assignment They were
given one days processing in connexion with their
entrance on active duty and received a three day intensive
orientation course before leaving for their units
72 Jan IJ l'»51
AUULOMYCIN IN SUPl'URAllVC I UROMHOPIU LlilllS
i-rutHix,
SUPI’URAl IVi: THROMBOIMH 1 RITIS
IRFAIID WIIII AljRIOMVClN
in
I) MiicG JACKSON, I RCS
{I rom the Mit'uiil hetmuh Ctmiii/ lliirnt Unit
llirmini,haiit Acitdeni //enfilnl)
Of the \'iiK'ii5 t>pcs of thromhophicbilis tlie infectiom
mil Aiippiir iti\t t iscs form onh 3'u (Hitler, 19Jt>
lhe\ in, often f It'll, liouc'cr oninj to tlic development
of p\ icmi 1 ind nicfist me foci I he followint; t ne of
ilio fcinor il thiombophlcbitiv is of pirtieiilir interest
for three reisons (1) the proj nosis wns nude worse
b> the infcetini, ori mism beitip a penicillin resist int
Sltiph\loioi.Lii\ aiiri IIS (2) i misfike wis probahK nude
in discontmiiinp the chemotherip> too cirl>, intl
(3) a successful reeoscrj w is ncscrthcless obt lined with
lureomjcin without sem litition proximil to the
thrombus
Caso llcport
A hii> lied 1 sears fell into i tnth of hot wuer and
received scvldv of his bael thighs and left srm The
eslcnt of the scilded nrev vns 2-t ' of the lsid> siirfsce
2 beint V hole shin loss
On idniivMOn he wis treated for shoe), with R'O ml of
phsim diirine the first 27 liniin the dressinc «ss done
seven hours ifter nd itssion md the tncleriolo,ical stubs
from the s,.sldcd surf ice at tint time }.tcw niicroso-ci onlv
Svsteinie penicillin vv is begun with an initial dose of 2*0 000
units and tlivn ^0 000 units four hotirl) f urthcr swabs tin
the fourth dij showed the presence of iit ph aureus and
Pseutlonionns psoounea
r uncos* YC I
soour. c'ilV
g 106
5 104
5 102),
Z lOG
98
n
uj'*/ (r??
lig
''.■•yAjA-Mi
lO 20 30 40 50
DAYS SINCE INJURY
AUnCOMYCIN
500MG daily
iaoti
g 106^
!? 104-
£ lOP.
2 lOO
m 98,
cca
u-tr
aa
-c S
83
A
O
cr
<
X
8
a
VAsAsr^- ^i) Arvijwc- AVv w
60 70 80 90 lOO
70
DAYS SINCE INJURY
Temperature chart durmfi the treatment of thrombophlebitis wit
aurcomycm
Onset <)/ Thtnml opMelntts — On the luth day the childs
h icinoi lohin was (>')' and a bottle of blood wav given
after tutting down on the rifhl (reat saphenoiiv vein at Ih
mile I our digs laicr hiv temp- atiire rme to 105 P
(•ill 6 C ) (sec ( hart) ind the pulse to IfiO the right calf
was prowl) swollen hoi and tender and die drip ireu on
was inllainrd Sgslcmic pcnieillin w iv incrct-ed to IfOOOO
units siv huHiIy and a eout’C of sulphadi itidine wav s arled
(2 S g mill illy then 0 * ( four hourl)) On ih* folloA n:
dav (I3lh) I small abscess was incised over the upper end
of the tibia and from the piiv a pi re p/ovili if p-n cillir
resistant Staph aureus was (town The local infiimmatci'a
lesion subsided during the nevl three days but as the
Icmperaiiire remained at 102 P (JS*) P) and It - ptilic
at IfO aiirco iiyein was h'pun on the lOth da) (37* rag
mi lall) then 125 mg su hourl)) On the 19 h day tender
indurated ihtumhsa cJ l p'tfivial veins appeared on Ih'
m'dial 81 le of the tight Ihiih cMcndirg to wiilm 2 in
(5 crrD of the pirction wi h the femoral sein v hi h was
not palpable I be tontae of sulp'udiiridine was stopp'd
nfier i mini dosape of 21 5 r the white cell count b'lng
5 0*0 per emn
Opera Ian on the I emorcl I eln—On the 21s' day it was
decid'd to lie the titbt saplcnois vein since the local signs
Jiigicvted invoivcin'nl of ibc sup' fi-ial veins only At
operation the sapbenouv ve n and tis traliitatics were
collapseil and e iipi) but the femoral vein wav foiird to
fie IbfomKaved ilioiigb il Itad t'cn impalpable II was
op'ned and some n* the vellow thrombus smeired I'n a
slide and lalen for tullurc the cxlerral ihac vein was
not ctplorcd and vv^v too small for an attempt at sucbing
out the clot The fc noral vein was li'd hut He ihronbus
w IS pilpiblc at least < la (1 25 cm) p vivimal to the hp
tiire Hie sni'ar showed well stained Oram positive cocci
and the culture yrew penicillin tesivtant SiapI aureus
Ithx'd cultures laLcn on the day of ep-etation nnd the
next two daw (21st 22nd and ^itd) xvere all sterile after
‘S hours An operation to tic the iliac xein aKavc th'
thronihiis was decided against i eciusc the childs conji'ion
was improving the orpinism was known to Ic sensitive to
rviircomycin blood cultures were n'^^tive and there was no
sign of m-iisialic sp eid liy the 2-llh vl-av eight daw after
aureoniycin was Slatted his clinical condition was much
heller and the Sirph aureus had entirely disappeared from
the siald On the 33rd day penicillin and auteomycin were
sloppcvl after total dosages of 24 If 0 000 units and 9 375 mg
respectively
Shin praliinp Operniioris — Tile graniilalinp areas "ere
covered with split skm grafts on the 27th and 39ih davs
and by the 4Sth day bcahng was complete and there was
no oedema of the leg or any pilpahlc veins
Pirst Iseciirrense o/ Psrexut — Tlircc diw later however,
the child hcc-inic ill ngam vviih a icmp'ratore swinging
between 99 nnd 103 8(37 2 nnd 39 4 C) Clinical exanii
nation and invcvticalionx rev cited no cause so thal after
three diys a recurrence of the previous infection vv is pre-
sumed in spite of a sicnie blood cuUiirc and aiiteonaycin
was rcstirtcd There was n rapid response and the drug
was discontinued after nine diys (total 4*00 mg)
irroiid heturrenct o/ Psresla — After a fiirllicr eight days
Ibc child s temperature acain rose to 102 5 i (39 15 C)
and agiin it was impossible to confirm Ihc diagnosis A
fiiribcr cxacerbiiion of the tlironiboplilgbitis was presumed
nnd a 28 day course of aiirconncm was begun The tempera
lure became normal m a week and did not rise agiin The
boy was discliirged at the end of tins course (14000 mg)
pcrfeclly fit and during the next 10 weeks showed no sign
of fiirllicr recurrence
Comment
The three lines of treatment in general use for this
condition arc antibiotics proximal ligation of the throm
bosed xein, and anticoagul int therapy
Jan 13 1951
AUREOMYCIN IN SUPPURATI\'E THROMBOPHLEBITIS
Bamsu
Medical Journal
73
There is no controversj about the use of chemo
therapy the most powerful drug against the particular
organism isolated should be given as soon as possible
m adequate dosage and for a sufficient period The
recurrence of the clinical picture of sepsis with too early
cessation of the drug has often been noticed — for
example, Hyman and Letter, 1944 Lyons (1941)
reported two consecutive cases of staphylococcal
cavernous sinus thrombophlebitis treated with sulpha-
thiazole and heparin with recov ery Each of these cases
had a bacteriaemia which lasted six and eight days
respectively and he advised continuing the sulpha-
thiazole for three months in a dosage sufficient to mam
tainAhe blood level at 5 mg per 100 ml Schall (1941)
reported three further cases of staphvlococcal cavernous
sinus thrombophlebitis successfully treated with sulpha
thiazole and heparin There is little doubt that if control
of the pyaemia can be obtained by chemotherapy for a
sufficient time this is likely to be successful in curing
the thrombophlebitis For staphylococcal infections the
antibiotic of choice is now aureomycin (Long 1950) and
Spink and Yow (1949) have reported five cases of
staphylococcal bacteriaemia treated with aureomycin,
with four recoveries
According to Van Duyn and Van Duyn (1940) the
idea of trying to stop the spread of infection from a
diseased vein into the general circulation originated with
John Hunter in 1793 when he advised putting a com-
press on the vein just above the suppuration Since
then and until the development of chemotherapy, the
mortality of suppurative thrombophlebitis has been pro
portional to the inaccessibility of the septic focus and
the difficulty of eradicating it (Rosenow and Brown
1938) Before the advent of sulphonamides vein liga-
tion was the only rational therapy but the mortality was
still high septic thrombophlebitis of the neck for
example had a mortality of 20-30% even with operation
(Iglauer 1942)
The present value of proximal ligation of the throm
bosed vein is more debatable Kern and Berman (1945)
reported a case of ilio femoral thrombophlebitis follow
mg pneumococcal lobar pneumonia empyema, and
septicaemia which proved resistant to sulphonamides
and dicoumarol the patient was cured however, after
ligation of the inferior vena cava above the thrombus
and a course of penicillin Which one of these pro
cedures played the major part in the patient s\ recovery
It was impossible to say, but they felt justified in stating
that the convalescence was very definitely shortened by
the surgical intervention and the danger of embolism,
minor or fatal was eliminated In contrast a case
described by Kirk (1947) illustrates that proximal liga-
tion without control of the pyaemia is likely to be
fatal His case of suppurative ilio femoral thrombo-
phlebitis due to Aerobactcr cloacae was temporarily
controlled with streptomycin but drug resistance deve
loped and when infection spread to the opposite side
the inferior vena cava was tied In spite of this the
patient developed septic meningitis on the sixth post
operative day and died two days later
In practice few would doubt the wisdom of proximal
hgation when the vein was easy of access when there
was, a positive blood culture and when the organism
was resistant to the drugs available Again there is
unlikelv to be disagreement m adopting a conservative
attitude if the site of the proximal end of the thrombus
IS inaccessible it repeated blood cultures have been nega
tive if the orgamsm is sensitive to the antibiotic and
there is serious concomitant disease Between these
two extremes it may be difficult to come to a decision,
but the chief indication for vein/ligation is inability to
control the bacteriaemia with antibiotics
Anticoagulant therapy is of less importance but as
It may prevent extension of the thrombus it should be
given when possible An ^pen wound such as was
present in the case described is of course an absolute '
contraindication It is interesting that both cases
described by Lyons (1941) developed pulmonary infarcts
while receiving heparin
Summary
A case of suppurative ilio femoral thrombophlebitis arose
from a transfusion incision infected with penicillin resistant
Staph aureus and this was treated with aureomycin At
operation the diagnosis was confirmed but because of the
organisms sensitivity to aureomycin the repeated negative
blood cultures and the sustained clinical improvement
proximal hgation was not performed Failure to give the
aureomycin for a sufficient penod initially is believed to
have resulted in two recurrences but after 125 mg had
been given six hourly for 28 days (total 14 000'mg) the
condition was finally cured The treatment of suppurative
thrombophlebitis has been considered brieffy
References
Barker N W (19341 Proc Mayo dm 9 191
Hyman A and Leiter H E (1944) J Mt Sinai Hasp 10 583
Iglauer S (1942) Arch Otolaryne Chicago 36 381
Kern H M and Berman E (1945) Amer J Surg 69 120
Kirk G D (1947) Ibid 73 606
Long P H (1950) Lanrei I 420
Lyons C (1941) Ann Surg 113 113
Rosenow E C and Brown A E (1938) Proc Mayo Chn
13 89 ,
Schall L A (1941) J Amer mei Ass 117 581 ^
Soink W W and Yow E M (1949) Ibid 141 964 v
Van Duyn E S and Van Duyn J (1940) Ann Surg 112
294
Medical Memoranda
Case of Ovarian Pregnancy
The occurrence of an ovarian pregnancy is still rare
enough to excite interest It is estimated to occur in
0 7-1 % of all ectopic pregnancies In recent years the
subject has often been reviewed (Isbell and Bacon
1947 Bolton 1949 Deweese, 1949) and the numbers
of authentic cases have been \ariously calculated as
approximately ^0 (Curtis 1941), 52 (Way 1941) and
50 (Novak 1947)
Case Report
A woman aged 21 marned for one month was admitted
to hospital on October 20 1949 complaining of pain in the
abdomen Four months before admission (three months
before marriage) she first had coitus Her next menstrual
period v.as 14 days late but otherwise normal The follow-
ing period Nvhich occurred 28 days later was normal She
then married and engaged in coitus but the menstrual period
which was imminent did not occur Se\en days after her
marriage «he sudden!) collapsed in the street and complained
of dizziness low abdominal pain and vomiting There was
no vaginal bleeding
She ^vas admitted to another hospital believed to be
suffering from acute food poisomng but was discharged
after three da\s though still complaining of intermittent
abdominal pain and she sta>ed in bed at home
A week later a profuse vaginal haemorrhage occurred
associated with abdominal pain localized to the left side
Large clots were passed and the bleeding lasted three days
/
74 J^s 13 1951
MCDICAL MEMORANDA
c*mTii
Hr fOkt icr *S4t
lliL pun slill pcr-iKial Ap ui from nn iniit\ tl ippcndic
ictonii two jcir\ prmoiiUj slic li id I'ccn ipnlc hcillli)
Mcnstriiiiion lic( in at 11 and hid hccn quite rend ir wilh
norm it lo<i'.
On idmission her icricnl condilmn wn ( ood llie rniiinii^
nicmbrincs uerc of nornni colour piihc ')2 temper iliire
97 8 1 (3fi 5S C) re^pintioin 20 blood prciMirc US/70
Tlic abdonan iioi diOendcd the w ill moved ftccl>
the iimbihciiv vvnv not diveolinircd There wm <ili,hl
Icndernevv in the left due fowl but rirulil) or free Oiiid
vv tv not detevtcd 1 vnmimtioti per viiirnm vhowed heilth)
MilvT ind iircthro vofiish inobdc cerviv Ihere wav no
cni irj,cnicnt of the iiteruv, whah w iv intevertcd but an)
nttempt to move it eiiived treil pelvic pun /\ tenrler ill
defined solid nnsv about 2 in cm ) in diameter vvav
palpable m the pouch of Roupliv ippjtciitl) conlimimiv
with the left idncvn Ihc ripht appcndaiev were normal
Per speculum i health) nullipatiuis cervix was seen
TTic urine was nornni A btoo I count showed leiico
c)tes 8 100 cr)tbroc>tes tOOOtXX) Incmoplobm 90'
A tentative dinnovis of a left c..topic pre, nine) was made
On the sixth d i) after admission a profuse vapinal
haeniorrha)c occurred with inod-rite pun in the left ibac
fossa rxplorator) lipirotoii) vv is then decided upon
Operoiioii — fins w is carried out bj one of us (I Ci ) on
October 2fi On opcmn\ the aldonen the p'tilonctim was
normal in colour and no free bleu I w is seen Uterus
tubes and rii,ltt osar) sscrc ni'rmil in app-irinte TTic
omentum ssas idlicrcnt to the po tenor as-Cet of the utenis
and left broad Iq ament li) films ulbesions wliidi separated
rcidil) rcvc ilin) the left uv irj to ssbicb w is atiaclied
a miss of blood clot the si/e of a tennis ball /\d)aceni
loops of idhcrcnt bowel sscrc p-elcd c'll casd) ind the mass
and about half of tbc os it) wen tcnioved No corpus
liiteiim w IS seen on the rq-bt ovar) nor was there macro
scopic csuicnce of endometriosis I be abdomen vsas then
closed in la)ers
Cons ilesccncc was uneventful the pilieni was ambulant
on the fourth di) ind w is discharied on the ninth post
operative di) Snlpinpotriph) performed on November 26
showed patenc) of both tubes
Paihi’loi.ic(il l\<rort (J 12 ) — TIic specimen consists of
about half of an osar), Uv the free surface of which h
attached a firm lamin iled ept. shaped mass of blood clot
4 cm in diameter On the cut surface of the ovar) a
corpus hilciim of pretinnc) 1 5 cm iii diuiiclcr is visible
On breaking awa) fragments of blood clot villi ire seen
m the neighbourhood of the corpus hitcuni and adjatenl
ovarian tissue No foetus vv is found Sections show
syncytial misses and chorionic silli emhedded in the
ovirian tissue and insading the corpus lulciini Man) of
the vilh ire ahead) deicncratcd The ovariin stroiiii is
excecdmglj vasculir but no pseudo deeidu il cells arc cvi
(Jent the ronal li)er is lieisil) infillriled wiiti pol)morphs
plisma cells and micropliqcs but this reaction is not seen
elsewhere in the ovar) The liistological picture of the
corpus liitciini coincides with , ill it of an cirt) pregnane)
with tbc cenird core oteiipicd b> a recent organiring clot
There is no evidence of ovirian cndomciriosis
\Vc vvisti to lliank Professor C Parqulinr Murray for Ills help-
ful suBgcsiions and for permission lo publish this case and
Mr D Ilarland for tiis tcclinicn] assistance
LGvN/rRCSCd MRCPI
Senior Registrar Department of Gynaecology
J E Ennis MB B S ,
^ Consutlam Pnlhologist
Dryburn Hospital
Durham
RnfcnpKccs
Bolton John P (1949) Ohio St med J 45 353
Curus A H (1941) Stirft Gynec Obstet 72 1039
Detveese W J (1949) Xfmn Med 32 272
Isbell N Paul nnd Bacon W B (1947) Amer 3 Obsu
- ^yucc 54 329
"’fJe CyimccoloRica) and Obslelrlcal Palholog
avo Saunders Philadelphia
Way S (1941) Brli J Obsiei Cynnee 48 473
Sfranfiulafed eSpifielian Hernia
Spipclnn herni i occurs ilon" Iqc scniilinar line, iisiially
ncir the level of Ihc Trcinic lipmicnl II I'cncirilcs the
broad fiscnl bind b) whicli the intern il oblique and
tf in vers ills muscles arc inverted iiiio the rccitiv sheath
but lies tinder Itie aponeurosis of the external oblique
muscle Ibis tense nponciirosis obveurej /the lumour
and maV cs it dilhtuU to palpate 1 be bernia has a tough
rijid neeV. and is often co cred b) a thick U)er of
extraperiioncil fit
Casp Kiioi't
A stout woman aged 65 with a lax p'mhiloiis ahdo"ien
bad a histur) over cveral yeirs of periodic abdo meal
distension and voniilinp somtlmi-s sviih rleriis of tie skin
and typical gall 1 1 idJ-r colic Cholcwyvtce omv was get
formcil in August I'l 7 Th' gill bladf-r svas small and
packed ssiih Slones lie torunon duct was free of sion's
Colic and i ten v were inmcdialel) relieved but tlm atta'ks
of disicrsiiin md vo nuing continued iinibalcd and b'cane
mote frequent as tunc pawed
On May 20 19 '9 vlr devc’op-d ‘iijdcn severe pain in
the ligbl line fossa This pam trivcllcd slowlv to th'
epqisirniM and then I came ( en'fali ed fhe most severe
pun was consianti) ii the ri hi line fossa \ omung b'gan
I2 hours after lie onset of svmpoms an 1 b'cam* verv
frequent ■-nd sohmnnoiis She svas admitted lo Mr J
Campbells siUi leal unit in tie Soutbp 'it I’ronienad
Hospital 20 hmus after lie onset of symptoms Oa
admission her Ic np'raliirc piiKe and reap ration were
normal Dehydration was obvious ami prsNlaim'd the
siolencc of Ihc vomiiing fend mess in the rtchl iliac
fossa ss IS extreme Ihe pilient vvm ed when th' exannn
ing hand had d me little more tint) tovcli th' slm A tense
oval swcihne al out 3 ly 2 m (7 5 by ' cm) was palpated
in ihc iqhl line fossa Ising within Ihc subslarcc of the
aldominal will pirallel with the ineuu il hgarrtnl and
about 21 in (6 2^ cm) above it
Strangulaicsl Spig'Iian 1 erma was diignos'd An inci
Sion vsas made over tbc swelling and live li'tnu vsas revealed
nficr Ihc external ohhqiic aponeurosis had I ecn incised The
SIC contained omentum and slringiilited loops of small
intestine vvhicli vvere kinked and bound together by touch
adhesions sueceslini a faulv ptoh'ujcd lenancs m rather
inadequate quarters The reck was rigid and crisped Ihc
sac tightly It w IS big enough to admit two fingers The
worst of the itlhcstons were divided and the intestine vvas
relumed lo Ihc aNlomcn where normal colour was tipully
regained The liycrs of Ihc uVulominal wall were defined
and Ihc wound repaired Recovery was uncsentful
CoMstrsT
This case IS interesting as the apparent continii ition
of symptoms following cholccvstcctonn were ascribed
to some rcMtliial Iiscr damigc for which she had been
treated The onset of nciite str inrul ition al first closely
mutated nciile appendicitis The correct diignosis was
given by the development of intestinal obstruction with
the presence and site of the tumour
Reid (1919) reports a case of Spigelian hermi which
imitited an acute ippcndicitis to perfection The above
case illustrates how deceptive this rire hernia cm be and
the advisability of beiring it in mind when abdominal
symptoms of an obscure nature arc found
Wo timnk Mr Jolin Campbell for permission to publish detmh
of tins ease
D Watson M B , Ch B
Bern ScoTina, MB BS
RncitCNCE
Reid D R K (1949) Brit J Sure as ta3
Jan 13, 1951
REVIEWS
British
Midjcju, Journal
75
Reviews
BLOOD GROUPS
Blood Groups in Man By R R Race Ph D
M R C S and Ruth Sanger Ph D B Sc (Pp 290
£1 lOs) Oxford BlacCuell Scientific Publications
1950
Ostensibly blood groups and clinical medicine have
been living together harmoniously for some 40 years
However the discovery some 20 years ago that there,were
human blood groups (M N, and P) of negligible impor-
tance in clinical medicine was a warning sign that the
ways might part sooner or later, though the discovery
of the Rh groups at first suggested that after all the
subjects might develop most rapidly if they worked
together
Since then great efforts have been made by both
sides to pretend that their interests are really the
same This has led to great concessions by clinicians
Clinical pathologists have struggled first with CDE then
with C" D" and E“ This book should persuade them
that the time has come to abandon the chase It is
useless to pretend any longer that what is interesting
and even fund imental in the fielcT of blood groups
IS necessarily of the slightest interest in clinical
medicine
It may come as a shock to some clinicians to find that
It IS possible to write a really first class book on blood
groups without giving any definite description of a
compatibility test This omission seems entirely
proper in a book which is not written primarily for
clinicians
From now on the clinical pathologist with a special
interest in blood groups must recognize that he cannot
aspire to more than amateur status in the subject His
daily work requires a knowledge of only small dis
connected parts of it Acquaintance with the phenotype
Le(a- b-) IS no more important to him than a know-
ledge of the rarer poisonous fungi On the other hand
to the geneticist each blood group system is of approxi
mately equal interest
This book IS written by two people who have done
more than any others to advance this subject in the last
few years and therefore every worker in this field should
study It closely However, this will prove far from
being a burden to anyone the whole work is enlivened
by a discreet gaiety and is the easiest possible reading
There are very few criticisms to make It is a little
surprising to find that haemolysis by anti Rh sera— a
phenomenon very difficult to demonstrate — is mentioned
twice whereas a and j8 haemolysins are not mentioned
at all The authors have been a little too respectful
of some published work It is unavoidable that a good
many bad papers have been published on blood groups
and if these are to be quoted the reader should be given
some clear indication that the conclusions are open to
doubt
These are verv minor reservations The book will
save blood group workers untold hours of hunting
through the literature Even more important, it will
make them familiar with the methods statistical and
otherwise which Race and Sanger have used to^deter
mine the pattern of so many new blood group systems
P L MOLLISON
WATER AND SALT DEPLETION
Water and Salt Depletion By H L Marriolt C B E
MD FRCP (Pp 80 15s) Oxford Blackwell
Scientific Publications 1950
This monograph is a reprint of Dr Marriott s Croonian
Lectures of 1946, which were first published in this
Journal The text has been revised to bring it up to
date He sets out, in the lucid, dogmatic fashion we
Jiav'e come to expect of him, the mam facts of salt and
water metabolism with the causes and effects of the
bodys depletion of each separately and of. the two com
bined The diagnostic and therapeutic precepts which
follow are simple and practical and have already estab
lished their value
Dr Marriott has clearly made valuable use of his war
time experience in India, and there are few points at
which anyone will cavil No comment is made on the
view, held by many that the urinary excretion of chloride
after operation' and injury bears little relation to the
plasma levels, and that the Fantus test is a fallacious
guide to treatment in such cases His suggestion that
salt depletion ' aggravates pyloric stenosis by super
imposing pylorospasm is interesting and explains the
unexpected improvement which sodium chloride will
, often &ring about in these patients His insistence on
the prior claim of the oral and rectal routes for adminis
(ration of fluid is salutary in these days of uncritical
intravenous medication
With this httle book in their hands, the junior resi
dents, upon whom to Dr Marriott s distress, the
''management of salt and water depletion so often
devolves, will be well equipped to meet these emergencies
R Bodlev Scott
MICROSCOPIC DIAGNOSIS OF MALARIA
Studies from the Institute for Medical Research
Federation of Malaya No 23 The Microscopic
Diagnosis of Human Malaria Part I A short
descnptive atlas of thick film diagnosis By John W
Field llluslrated by Yap Loy Fong (Pp 1)6
illustrated No price ) Federated Malay States
Institute for Medical Research 1948
In the early days of malaria research technique was
practically restricted to making the wet blood film a
delicate operation not to be attempted except m the
seclusion of the hospital ward Later with increasing
convemence and usefulness came the dried film, watery
Romanowsky, Leishman stain and Giemsa But
meanwhile more and more was demanded from the
malaria research officer There came the increasing use
of the thick film with its added difficulties in inter
pretation,. counts were required for certain kinds of
work diagnosis of the parasite became mcreasingly more
important as drug treatment became more precise and
specific, and in wartime examination of blood films had
to be made on a very large routine scale Many
beginning such work found there were troubles-and
difficulties to be surmounted and advice of the detailed
and practical nature required was not easy to get
This helpful publication is designed to meet just such
needs Dr I W Field has set out in the simplest and
most direct manner, and in full detail with copious
illustrations a description of practical requirements in
the making and examination of blood films by (he
malariologist After a brief account of the forms and
appearances of the malaria parasites and points regard
ing parasitaemia and other matters of importance m
the examination of the blood in malaria, there is a
chapter on the thick film and one on interpretation of
76 13. loM
pnvicws
^^hll K shown in iich Tilnn Thu n fnihi triJ h> i
ilcscnp ion of \ itioiis tcchnuiucs now ii*cd hj the
nnhrioloi Kt in llic nniirij uni cviminnion of Wool
liinn into inition on (he \ uuhu Uonnnowily duns
the m it nu o' film, for lonimc lu p* i iJ u -ij »• uicl lod
of loiinl in dfluh of Gienl'i Itininj fo.
tlilKtcnt snupu" hhcihnr of slid- ni d oilier it fnl
pratuil hints I lie nine of the wnil he% not onl> in
the \tn full del 111 foin, htil in th- cMent to win h
the luthor s osn inlmnte exp ri-n-c t Uu'-j uit-d
Tlic rciicwtr Itiouv of no uorS ijmic co iifx h’c ird
Ins no hcMtttiun in 'ifinf lint it will le iHcfiil wort
of e'e eiue .nd ) nm tree no' onK to the I finiicr In t
to ill cn, I sd in \ o t o' ih- lind s hn-lt i*i<- -uitliot
dn..tKM., Hit) MD Cimt toniiij
Annus i's\cf!(uof.N
At'Ut I l"t ! Ifseli’i t It], trinWj) (f'p 3)4
I*-'! I o I'l 1 (i i,r M -1 SI It ‘to in IV'O
AltteJ \dl'i s n un- iMiflctt tnci't oned folh ins.o'ilj
lu IS one of til ct -1 itu ! Jmu si d \d!cr \Siiti |i m
re .IS o t lie 1 n fc\ c itehwoids ill It h ISC 1 .O' c pot
of onr dsil) lunuif jinone th-ni iii'c lO its eoinp ex,
ssiUtops'er inx vuh le pto'c t Ih ext— it to sIikS
tl.e pntriplc o' his imlis dud p )..hoto s hxsc h-en
iib'Orh-sl into turtcnt P'Seniin, ihoii lit is itdi,. t-d
onl) hs the ircnu-PG ' 'th s’lntli ll e, sre rc hi oseted
s it'i ind ssiilunii nool d mm'
'‘find is in nlisttitiiun uid ttun- nho ssmild rcdiec
Its III imfeit itions to tciiiis of pluici of ip cc of fescis
ltd dipths must {I ltd SI urist cm ntiv eo ifu lot lest
their p nho" im hc-omc ill sjmhol ind no mmd It
IS fot this re ison tint Adlers ssoti Ins often stirxcled
the phjsieiui ssho doutils the sslutil)' of th- I retidun
hhicpnnt of mcntsl life the oriptnil sso ts tnsc lost
a {00 I d. i1 in irsnslition uul «inec lhc> hise iiescr
hecn piescnicd is more linn sober ids inecs in mediesl
cieiiet they hise been re id niiinly b) iptnbsls
Inf ilhbihiy Ins not been chimed fo- ihc uivhor Ccr
tiinls Adler s principles nrc riles mt to th- prc'cnt p c
oceupuion ssilh psychoionntic mcdieinc iind soci il
psychntrv Mr V>iis Ins iclncscd more tlnn ii rest lie
nient of them, ihoit{h he his done tin f.xiihfulls lie
Ins ntlempiLd the dilhciilt l isl of fin Imi their soiirecs
nnd rel itionships md of irieine the desekspmem of
Adler s theories ihrouEl) the life of the nnn himself
As i person il friend of Adler s sml no me in student
of philosophy he is sscll qinlified to do tins IIis
description of the unexsy colhborilion hcisscen Adler
and I rciid in the c iris days of the psycho .in ilstic mosc
mint, nnd boss the itiitiide of cich adminh'c in Ins
own ss ly sv is moulded by Ins ossn person itity niihcs
fnscimtinp re idiny In his h mils the historicxl ippronch
to the tinclcd web of present dns theory in psycho
pitliolotJ brinis sonic order into the siliiilion fins
bool IS no Adler Wuhonl Tears nor is it n synopsis
It is not all easy rciding but it is n rcisoncd uni
scho'ariy presentation ol the iniplic iCioiis of 'induiilnit
psycholoty in many fields inchidini that of medicine
ind there is here little to sshich the physician could take
exception
This IS an important book sshich challcnEcs much
that is accepted by many psyclii ilrists Not only svitl
It be a saluabic companion to Adlers svork but it is an
admirable book (or the mature physician sshosc expen
cnee has taught him that to knosv the naturil history
, of illness he must study not only disease but man
ALLXANDCR KtNNCDV
rnfMK,\r vmswioc:\
( till tri t t!rr lien I rl rn I Intln’n ir I's Dr 1 N
X 1 1 Ir S-eon I c.li i<m (I'p 1) *I 7JU) Jcaa
t.i 'IS 1 1 1 !) r I'i'O
ihc author of this hoot on the oii'linc- of ch-a- -M
pissiulti I frcit tl- tubject from Ihc p'l lolo-'ica!
•i p et nlhct tlnn tic cfi-tmcal Thus ii- ri'*s oa.y
an clement tty lee Hint of the c'lcmis'rs of ciiba*is£!rat <,
fats an I p otems iim'er th- heuhn, dues nn lie gisct
line del Ills imd-r mkrtn di,rs m-.ahol.sm sih- t th-
tea 'e niiy fin I t'c ril nl II) th- •efen- of t' e r'i->
r'n y'linn of {'if i ic uul its coasc » nn to 1 etic mJ
in 11 U vfc an I to dio' o! aa I catbon I'loxii'c bs yeas'
(It lie /’ i)\i Jxtioa of falx -ml (3l at lome l-a-tS tr-
oldrr Inosicd, e of ihe coascrxion of ammo a- ds (a
timit e- Hid of ltsp'o,i' m to ii I'l in The de'isdro— ra
lioa p 11 c's-x ssil'i s It uul CO fc ni n's is eenlils
del nil'! Oil kSa-biuj s ttsprvtna fc i cal is co-
X I'c cd Csto uoair is not n calioac 1 nn is i-c clia
i idcf ducstii’a h It > lai- of I'lslos s sso t is thscuss-J
Ihc Xt.oi nt of fo'il metal o'uai it I'nt o' \oi’ and
I’cilen' o'er the c is noiliia- alo ii t' c sso » o' \t s-nc
an' I!-n Jut na ih- simp'-r ssjys of s'ulsme oxseea
t I'xVc and cx lot I'lOXi *c iHItp it The ssork of plisxio
lo isti o I'l I'l tie niuiy 11 oanii d
Ihc he t e'np cr is ihit o i Wood Tf e ai"’ior rc-ardi
liicmop'iiiu III due to a dis'n bin-c of I'Toaihin and
ntilhromhi’i foim tion lie often deierih-s I’.c com
puiltsc j'lssiali y m o'he arinnh sslie'i adds some
inie Cat Inc hit puc is dcsot-il to i sc s short i eouat
of ill- me of luhoafiiic |< I op s The hook is dis
ipj" nlme set mij he ol s due 'o Gctn an s ud ntt
Out I njh'h bos'is on bioelicimstrs and passoU'cs are
r clerabie R It A Puwai
HOOKS' itrcrikED
f.n r* h nU p-rvU 'r I bf rt i t here cf I i t fr-e-tfi- rr-tnel
Prnbtrm 1 nniliei in Itriitnl tU R C i M
ni 11 HT I"' ta' y lom'pn Cxi It I'ltO
7de i\atioml flfiUli C/rrirr \rli is>/< nnrf ttv J A
Son out, SI ty ni‘11, mj cict» ti’p i i9i
tiixdon I x[t nnd Spo umoixlc IVH>
7/c IhuelirnrirtrY fif )) liftnoitt Ilv R J SSidnies -nd
oit-rj (Ip 7.1 '1)0 tendon Onpaixa and llxll td'O
1 1tem tf nut nndidi-i Ry O \Sins'p» llo mex MD and
M D S hull M D (Pp 3X7 Sli (al 1 I ondon llcnrx
Kinipion tyso
Meitieiit rrettimenr It) 0 IZsanx MD^TRCP (Pp td9S
ID'S) tondin hiillcrworili list
Pte I iinl linnelteii fe\ intlsirirninfii tli Vi Kemper (Pp lOI-
M 5 70 or 3t 35) buiUiaii Gcotp lliicnic ID'O
Iftlfittlrii plr den Cet nrltlnlfliel en Olfriitw) tines hf
llic laic Piofcaxoi A Dodcitciix icviacd 1) I’lofcasor O
Dodcilcin ttp 173 M 7 50 Or Slid) Siuiipul Georg
lliicnic 19S0
Prnlnltnn dee Witlitigsitn Infeltionibraikleilen Rf Ihi
Inic I’lofcssor C Ilc|lcr reused bv I rofessor II E Unte
(Pp 377 M 14 70 01 S3 50 ) Stimpnrl Ucofi IliiCnic 1930
Ampntterte nnd PrflOtesen D) Dr R Cilc (Pp 3S
M 3 to ) Jcntl GusIih' I isclicr 1950
Cl ttnd/a^en dee ndl ohi^ie Ry Professor 11 Martiiu
(Pp 144 M 33 40 or $S 55) SlUUgxrt Gcorp Tliicmc I9S0
Atlas der Nonualen J1istotcn;ie nnd Mil eosAapiselien A natninif
des Mettselten Ry Piofcssor E Von ilcrraUi nnd Professor S
Abramme (Pp )39 M 4S ) Snillgart Georg TJiicmi I9S0
Jan 13 1951
MEDICINE IN AUSTRALIA
Brittsii
MEDtCAL Journal
77
BRITISH MEDICAL JOURNAL
LONDON
SATURDAY JANUARY 13 1951
MEDICINE IN AUSTRALU
On January 1 1901 the Commonwealth of Australia
was inaugurated by the union of the six Colonies
which had each had a separate Government up to
tkat time It is fitting therefore that our contem
porary the Medical Journal of Australia should for
Its first issue of 1951 publish a jubilee number which
reviews the status of medicine in Australia at the
beginning of the century and its progress and develop
ment m the last 50 years The 14 papers m this
special issue are not only eminently readable but
together they make a useful contnbution to Austra
han domestic history
During the nineteenth century the medical practi-
titioners of Australia had come from abroad having
been trained m England Scotland Ireland and more
rarely on the Continent of Europe but towards the
end of the century medical schools had been estab
lished in Sydney Adelaide and Melbourne from
which already a limited number of practitioners quali
Tied each year In the towns the family practitioner
held a position of trust similar to that of the family
solicitor and banker and his advice was asked about
many matters of importance to the family apart from
illness Consultants in the capitals of the States
visited patients with the family practitioner and also
saw them at their consultmg rooms In the country
conditions were different largely because modem
transport had not broken down the isolation of rural
communities it was not unusual for a doctor to ride
on horseback to visit a patient some 20 miles from
his home or to drive in a horse buggy Motor cars
came in during the first decade of the new century
but the country roads were as a rule bad and it was
often impossible most of the year to approach the
farms m a car
At the present time half the population of Australia
IS concentrated in the State capital cities and most
of the remainder five m the more fertile coastal areas
of Southern Queensland along the borders of New
South Wales and Victoria and on the south coasts
of South and Western Australia Conditions m the
big cities are much the same as in other well
populated countries the treatment of illness being
undertaken by the family practitioner with the assis-
tance of a hospital easily available The centres of
medical work and teaching are the hospitals These
were built in the early days mainly for the desUtute
sick the visiting doctors giving their services free In
the country towns hospitals were often built as in
this country as memorials to some person m the dis
trict During the past 50 years hospitals in Australia
have grown in importance and their' function has
been enlarged to include not only treatment of the
sick poor but other senously ill patients Small
private hospitals in the suburbs and country towns
were established especially for maternity and minor
surgical cases but gradually these have had to give
up through being unable to meet increasing costs
New hospitals m the big centres have been built on
modem lines (there are some impressive photographs
of these in the Commonwealth Jubilee Number of
the Medical Journal of Australia) and accommoda
tion has been provided for the practice of many
specialties All this of course means that more nurses
and auxdiary staff are required The cost of build
mg too has increased for it used to be possible to
build a hospital for £200 or £300 per bed but now it
may be ten times as much The expense of providing
accommodation for nurses and other staff is equally
heavy, and the Government has therefore had to step
m and help to build equip and maintain hospitals
Naturally with the growth of population there has
been an increasing demand for doctors and for a
standard of medical care equal to the best obtainable
in other parts of the world This has been hastened
by the impact of two world wars on Australia
Gradually medicine became a more attractive pro
fession and many more doctors were trained locally
Some of the best of these came to Great Britain and
settled m various posts others having been over
during the first world war and having taken a higher
qualification returned to raise the standard of prac-
tice in their own home towns No great local dis
covenes were made in these early days but no time
was lost in applying in Australia the results of world
wide advances in medicme and surgery It was
dunng the second world war that rapid progress was
made by Australian research workers especially m
solving the many problems ansmg m tropical war-
fare New knowledge of malana and dysentery
proved of the greatest value to the medical services
of the British and Umted States Forces The impor
lance of medical research in Australia has just been
fittingly recognized by the award announced m the
recent Birthday Honours of a knighthood to Professor
F M Burnet, of Melbourne The standard maintained
m the medical schools of Australia has always been
high Nearly all the early professors who went to
teach the basic sciences were Fellows of the Royal
Society vvith international reputations The stimulus
these men gave to then students was carried on into
then- hospital trammg where the teachers were fir-
/■
Jan 13 1951
COLONIAL MEDICAL SERVICE
BRVron
Medical Journal
79
due pnmanly to unsatisfactory rates of pay but an
equally powerful reason for lack of recruits may be
a lingering suspicion that out of date methods of
medical administration are still to be found in some
places Professor G Macdonald’ has pointed out
how shortage of doctors m some Colonies leads to a
heavy emphasis on routine work a consequent lessen
mg of interest m research which m its turn again
impairs recruitment Much was hoped of the en
courageraent to medical research which would come
from the establishment m 1949 of the Colonial Re
search Service but so far these hopes have not had
much to justify them
About three months ago the House of Lords de-
bated the subject of medical man power ‘ and several
speakers took the view that the best way of overcom-
ing the shortage of doctors in the Forces and Colonial
Service was to enable men and women to transfer
freely without loss of pension and other rights from
one service including of course the N H S to another
The natural corollary was as Lord Haden Guest
pointed out that the payment received by medical
officers in the three Services and m the Colomal Medi
cal Service should be equal to that received in the
National Health Service The Government spokes
man in this debate Lord Shepherd was obviously
impressed by the arguments put forward and told
the House that he hoped something good would come
from the deliberations of the interdepartmental com
niittee which was considermg the co ordination of
medical services The thm end of what is hoped will
eventually be a large wedge has already enabled
doctors in the N H S to transfer for a limited penod
to the Colonial Medical Service without loss of super
annuation rights’ (and with the grant of a gratuity
at the completion of their service) and m West
Afnca young doctors accepting certain Colomal
Office posts are thereby able to discharge their
liability to military serMce
For many months past the Colonies and Depen
dencies Committee of the B M A has been negoUa
ting with the Colomal Office “to achieve a broad
equality of reward not the same figures m
pounds shillings and pence but the same real return
for services rendered in each temtory a return which
IS comparable with the remuneration of doctors m
the National Health Service”* From time to time
agreement has been reached on revised scales of pay
in certain Colonies * and though much remams to
be done it is clear that the Colonial Office fs as
anxious as the BMA that Colonial Governments
will take sensible steps to attract good medical men
to their service In East and Central Africa for
instance the salary of a medical officer in the ordinary
arade used to nse from £865 to £1 320 Under a new
agreement it now rises to £1 590 This may be
compared with the salary of £850 rising to £1 150
awarded by the Industrial Court to assistant medical
officers m the public health service in this country
Further the income tax payable by a single man at
the beginning of the assistant medical officer scale
in this country is about £200 In East Africa it is
about £75
In the past complaints have been made that
the information given to applicants for posts in the
Colomes has been inadequate or even on occa-
sion misleading The Colonial Office has recently
taken steps to remove this cause of dissatisfaction
There are of course stdl many anomalies and unsatis
factory features about conditions of service for
doctors in the Colonies The thorny problem of pn-
vate practice by colonial medical officers remains un
solved The position of the clinical special st vw a vis
the administrator may not always be happy — bad
“ man management ” is still sometimes responsible for
much bitterness In general specialists arc recruited
from men already m the“service but a concession has
recently been made to men with higher qualifications
who may be thinking of joining the Colonial Medical
Service for in some Colonies they may begin their ser
vice higher up the salary scale than less well qualified
entrants Though no guarantee can be gived that a
young medical officer will be employed m his specialty
the Colonial Office states that directors of medical ser-
vices would see that such a man was given as much
work m his own subject as possible
The attraction of medical work in the Colonies has
always of course appealed only to relatively few of
those who qualify and this was so even in the days
when reraunerauon was much better than that obtain
able by doctors in civd practice in this country To
some life in a particular Colony may have attractions
which more than counteract poor conditions of ser-
vice and to others no financial inducement could pos
sibly overcome their dislike of living abroad Any
one who joins a service knows fairly well the sort of
disadvantages which are inescapable m even the
most bemgn of hierarchies It is unlikely that any
single disadvantage — separation from home and often
from families the inadequacy of salaries m some
Colonies the expense of educating children at home
early reUrement — would deter doctors who might be
attracted to the work but the total effect of these
doubts IS discouraging However there are signs
that Colomal Governments which wish to build up
medical services comparable to those in this country
realize that they must provide for their medical officers
condiuons of service at least the equal of those obtain
able m Bniain and some practical steps have already
been taken to this end /
Jan n, 1951
Oi^CRATING THEATRE TECHNICIANS
Bwntn
Midical Jolrnal
81
standpoint he will ha\e as part of his team a member
who out stays the ever chanting theatre staffs and a
craftsman who by learning each surgeon s fads and
habits eliminates minor frictions and produces the right
tool in good condition a\ the right time thus leading to
the development of a partnership of trust and efficiency
essential to the quiet work of good surgery In order
to attract the right type of man the high standard of
training set by the association itself must be maintained
and recognized, and the association is now engaged in
negotiation with the Whitlev Council on this issue Its
work deserves the full support of the medical profession,
for if operating theatre technicians are graded in the
same category as theatre porters or orderlies the whole
aim and object of the association will be lost
QUINCEhiTENARY AT GLASGOW
Just 500 years ago in Januarv, 1451 William Turnbull,
Bishop of Glasgow, founded a university the fourth to
be established in the British Isles On that date Pope
Nichohj V issued the bull granting permission for its
formation and for its students to be licensed to teach
anywhere in the civilized Christian world but for many
years after the foundation was extremely poor, and
indeed Turnbulls original purpose was probably little
more than to tram clergy for his own diocese It was
only the faculty of arts that flourished and its college
began building in 1453 m the High Street near the
Cathedral at a time when Glasgows total population
was no more than 3 000 or so
from such small beginnings through years of
obscurity the ecclesiastical crisis of the Reformation,
and the struggles between Presbyterianism and Epis
copacy in the seventeenth century the university
struggled on and grew and began to (lower in the Age
of Enlightenment the eighteenth century, despite the
nepotism and small personal feuds that were then so
rife Glasgow was growing too as a result of trade
with the American colonies from 14 000 in 1712 to
83 000 in 1801 and the foundation of the Royal
Infirmary in 1794 provided a hospital on which to base
the medical school A professor of medicine had been
elected as early as 1637 but the chair lapsed in 1646
and was re established in 1713 to be followed in 1720
by a chair of anatomy with botany The duties of the
professors were to give lectures if five students pre
sented themselves and to examine candidates trained
elsewhere for the MD degree
U vvas the vigour and enthusiasm of the famous
Cullen which set the medical school on ns feet After
lecturing in his own private school he vvas brought into
the university in 1746 and from this time and that of
his pupil and successor Joseph Black who discovered
carbon dioxide and made Glasgow an important chemi
cal centre there was nearly alvvavs an annual enrolment
of 100-200 medical students among them such men as
William Hunter and Smellie ihd obstetrician The nine
teenth centurv saw a further vast expansion and con-
solidation under such men as Thomas Graham the
physipl chemist who first studied osmosis and colloids.
and Joseph Lister who carried out his famous cxperi
ments on antisepsis while he vvas professor of surgery —
at the suggestion of the then p ofessor of chemistry, who
1 new of Pasteurs work To day on its 500ih birthday
the university which has done so much to shape
Scottish life IS one of the leading academic centres of
Britain, and educates 7,000 students annuallv to play
their part in schol irship and leaching in government
and law and medicine May it in due course celebrate
a successful millennium
COMMITTEE TO STUDT GENERAL PRACITCE
The Central Health Services Council has appointed a
committee to study general practice under the National
Health Service Its terms of reference are to consider
and make a report on whether the existing-arrangemcnts
for engaging in general practice under the National
Health Service are such as to enable general medical
practitioners to provide the best possible standard of
service and in particular, to advise upon (1) the range
of work and standards of practice which should be
expected from the general 'practitioner by the public
and medical profession (2) types of general practice
(3) mode of entry into general practice (4) non medical
help, (5) equipment and environment (6) method of
remuneration (7) liaison with hospital and specialist
services , (S) liaison with local luthority services
The members are Professor Sir Henry Cohen (Liver
pool) chairman , Dr G O Barber (Dunmow) Dr S C
Barnes (Wirral) Mr N F Baylis (Clerk Nottingham
County and City Executive Council) Dr W Russell
Brain, P R C P , Dp J A Brown (Birmingham) Dr
B Cardew (Genera! Secretary Medical Practitioners
Union) Dr H Guy Dam (Birmingham), Sir Allen
Daley (Mcdieal Officer of Health and School Medical
Officer LCC) Dr E A Gregg (Chairman of Council
of B M A ) Dr W V Howells (Swansea) Dr Emd
Hughes (Ruthin) Alderman Mrs V F King (chair
man Southampton Executive Council) Professor Hilda
Lloyd P R C O G Dr W N Pickles (Aysgarth) ,
Dr A Talbot Rogers (Bromley, Kent) Mr E \V
Scorer (member of Sheffield Regional Hospital Board)
Dr Stephen Taylor (London) Dr J S Thomas (Manor
Park, London), Mr H P Travis (Secretary, Bolton
Hospital Management Committee) Sir Cecil Waleley
P R C S Dr C W Walker (Cambridge) The secre
larv IS Mr H N Roffey of the Ministry of Health
Any person or body wishing to submit evidence to
the committee should first give notice to the secretary.
Room 358 Ministry of Health Caxton House, Tothill
Street London S W I
We record with regret the death on January 3 of Sir
Arthur Hall in Sheffield at the age of 84 He was
emeritus professor of medicine in the University of
Sheffield with the foundation of which in 1905 he was
closely concerned
N’ n I'^M
A< I II III O' ( Hill'
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r iri m ilrs itfiiosp'icics \slirtli'-| Ilie cliniitc b- 111.11..
or Iropicil II IS ilso less to iiio.'n in oiif siimnirr linn
in oiir ss inter lliil ihe tonnccion 1111) liol b- so ilircvl
IS It setnis for on foi i > il mip mil coM ih\s peop’r
tend to son( rt( ilc in umlciscnld ilril iiriotimlims iiul
tills IS fisoiiribk to the sprciil of infetlion lliis mi\
ivtll be more import ml linn m\ pioprrlv of lltetlmnle
ilstif Morcostr Ihcrc iii Ik t ililfeicntc of b iticiio
lopicil cnMronmcnl in diffeienl tliniilic toiiiliiions -
Intmohiic sirtplocotti for csmiplc lend lo distppeir
from till Ihroils of rliciiinilit sub)ccls isticn llte> |o lo
siibiropicd dim lies uul lo rt ippi ir on rcliirn to i
Itmptrilt Aint so tint i( iiti oh it seems to be ii
climilic fitlor 111 ly in ficl be Iu|cly i Intlcnolo, K il
one
On llic other hind in bronchilis no miiform Intlcrio
logy Ins been cslibhshcd — A/itrocon in < (irnrr/m/n
sliphylococci pneumococci iiid sirtplocotci immii
others m ly ill ht found Infeclion seems lo pi ly nn
overwhelming pirt in infmls Ihe hiby often h ivinp
very hllle resist incc lo orginisnis 10 ivliich in I ilcr life
he will become more adiplcd In the ndiill il is
possible tint both fictors pi ly i pirl
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from the ttiehci nfir t'utifo'omy b i iii 11 m\ e n '
no pilho ctik orpiimnii itc found 1 id Ihe c lusc 11 is
then ssrll be a situs
ll is ills iss dilluiill to tiss-ss ill- pio nosis in 1 n t'
thcicforr sifcr to uhmt most eas s to hospilil A If"
tiscs ssdl rrnuirc Inetico'oms uul in Ihrse delis i'
dint crons tlie decisio 1 to op-rtle suit 1 bned on the
iiniouiil of reee sion of the soft pirK of llic ehest diiiine
inspir.dioti the pulse iiml Ihe tenet d eondilion~i ehd.l
sslio ‘trill I'Ics md puls up i In hi tins t el ihri'Uth on
Its ossn hill the pile hsllcss eroiips ehdd iisinlts
requires Irieluolumy
Most of tlie niodirdc e ises pel sscll on Ihcir o'sn
nnd this iinkcs 11 ddlicult to assess Ihe s due of ms
remedy Our routine is to iise a mivtiirc conliiiiini,
5 mi of pethidine thue nines i d is nnd d50(HK) iimis
of pemedhn csers six hours On Ibis rcj mie sen te"
Jan 13 1951
ACUTE BRONCHITIS
Bmtoi
Medical Joctcsal
S3
cases require tracheotom} but whether reco\cry is due
to the treatment or not it is difficult to sa> We ha\e
also used chloramphenicol in quite a few cases, and in
some dramatic improvement has been apparent In
hospitals where croup is a common cause of admission
there will probably be more scepticism about the value
of the drug than in hospitals where only the occasional
urgent case is admitted At the moment it is probably
idvisable to try the drug m all serious cases With
regard to steam treatment the tendency is to use this
less and less but in the well chosen dry case its
effect can be very satisfactory
Acute Bronchitis
This IS not always an easy disease to diagnose in very
voung infants apart from the fact that the baby is
obviously ill, there may be very little to go on The
temperature is often raised to 102-103 F (38 9-
39 4 C ) and respiration may be noticeably increased
On the other hand, symptoms may be referred to other
systems diarrhoea and vomiting are quite often the
presenting features or restlessness and irritability may
be so pronounced as to suggest the possibility of menin
gitis Exgmination of the chest may be of little help
a few moist sounds may be heard but noises arc
frequently referred from the nasopharynx In fact
diagnosis will often be conjectural and will depend
largely on excluding other causes of pyrexia In the
older infant as the time of teething is approached the
disease tends to be less acute and the symptoms more
tvpicdl of bronchial infection
The severe case is a medical emergency and in most
instances is probably better in hospital The social
background in many cases is important but the prime
cause in nearly all is infection and it is therefore
rational to use anti infective agents Penicillin is often
effectise and can be gisen orally to infants under 3
months old 50 000 to 100 000 uruts dissohed in a few
millilitres of normal saline can be added to each feed
or in the case of a breast fed infant can be gisen by
spoon after the feed either in saline or added to a little
expressed breast milk this dosage may be excessive
but It guarantees therapeutic concentrations To older
infants because of the destructive action of gastric
icidity on the drug penicillin should be given bv
repeated intramuscular injection if done si ilfullv this
IS not so upsetting as might be supposed Sulphon
amides in the form of a sweetened suspension arc often
of value One tablet (0 5 g ) of sulphatriad — a combi
nation of sulphadiazinc sulphamcrazine and sulpha
thiazole in one tablet — can be given four hourly to
a voung infant for the first 24 hours and thereafter
0 25 g four hourly for the next three or four davs it
IS not often necessary to give the drug for a longer
time Cough mixtures of anv kind arc undesirable in
infanev is thev mav upset digestion without affecting
the bronchitis
So far as is possible the feeding of the child should
not be interfered with and if a breast fed baby is
admitted to hospital the mother ought to be admitted
too breast feeding bv a mother visiting the hospital
for each feed is rarelv successful unless the home is
verv near the hospital If the mother cannot be admitted
the infant should if possible be treated at home The
child must be kept warm and must not be disturbed
unneccssarilv and bathing except to remove soiling
ehould be forbidden Manv of the more Severe cases
will require oxvgcn ard the onlv satisfactorv ways of
giving It to babies are in an oxygen tent or better still
m a perspex oxvgcn box
The above treatment is that required for a severe
case, and a large proportion of the younger cases arc
severe For less acute cases careful nursing, feeding
and warmth will be sufficient
Acute BronctiiolilLs
In infants this is usually a fulminating condition
death occurring within a few hours The diagnosis
IS often made only at necropsy when the sole macro
scopic finding is that thin mucopus can be expressed
from some of the finer bronchioles on section some
bronchioles will be seen to be packed with pus cells
and the surrounding alveolar spaces may contain fibrin
with or without some pus cells Pathologically the
condition is therefore not readily distinguishable from
early bronchopneumonia except that death h is prevented
the full development of the pathological picture We
have seen the condition develop m infants already in
hospital for other conditions but most cases arrive m
extremts and death occurs shortly after admission
Abnormal physical signs are not usually present and
the condition can be suspected only in an infant who
within a matter of hours becomes desperately ill
possibly with evidence of acute respiratory distress
Emergency treatment vvith oxygen and warmth is
obviously required and if the child can be brought
through the first few hours treatment as outlined for
acute bronchitis must then be energetically pursued
I
Clinical Mamfestations in Older Children
In toddlers and school children there is a marked
change in the aetiology and clinical manifestations of
acute bronchitis The disease loses much of its immcdi
ate severity and death due to uncomplicated bronchitis
IS rare Acute laryngo trachco bronchitis still occurs,
but It IS less common and in the older child the condi
tion IS less severe There are no cases of acute bronchio
htis corresponding to the fulminating type seen in
infancy when the inflammatory condition extends, the
clinical manifestations tend to be rather those of defi
nite bronchopneumonia On the other hand bronchitis
causes much of the minor illness of childhood and is
responsible for much debility and poor health In a
proportion of cases bronchitis may represent the early
stages of later chronic conditions such as bronchiectasis
While acute bronchitis quite often occurs in perfcctlv
healthy children frequently it arises apparently by
cxt"nston from chronic sources of infection in the
upp^r respiratory tract The problem of what are
and what are not unhealthy tonsils and adenoids is
a question one has no desire to discuss but most
practitioners have seen at least some children in whom
a succession of colds and attacks of bronchitis have
stopjied onlv after the removal of the tonsils and
adenoids Whether in the successful cases the tonsils
and adenoids have themselves been acting as sources of
infection or whether mouth breathing has been more
responsible for the bronchitis one cannot sav Chronic
nasal catarrh often associated with enlarged adenoids
also seems to be causally related to repeated attacks of
bronchitis as docs chronic infection of the sinuses
What the precipitating factors are and whether climatic
conditions are as important as thev appear are matters
for conjecture The bactenologv is always difficult to
establish but in some casts at least there is evidence /
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n lliis sloe III llll. bilicf tint llic) "ill 'nlc oil llr
nt itt tin. mini rcmll n i 'ctiic iHne" \llet llic
fif'l tl i\ in nio'i t itc' the tpiilnm b-'.oin- ittoic ( lo
fust mil llll. toiijli ci'iei Ikn!tt.lu mil inilooib
ippcir mil ifttr ["o or ilirti. ili" in bcil llic pnitiii
bt.j ins lo ficl uiiilc "til illlioiiili tlill iioiiblfil "ilh
i tout li Most pniiiils lie lip mil ibniil ni iin "nliin
stten to ten di>s
Ls mnniilion of llit tli si "ill itveil nolhiiu bitoiul
some Inrslmtss of llit bic nil Mnimls mil probibl>
clifTiist moist rilts I litre nrt no art is of tfiillness
in I sotil frtmniis is nol ilfttlnl
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t> S > , ' 1* IS - J ' A I t f
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I If I 11* It ' s I* ' f 1 K ' I ' 1- ' I ' A
(,i I I’l'
InC 1111-1 111 n I'l Slixi'iO S|fi-*riOiis
In « (' S I Itil'i 1 lit - I t n 11 ' |1 I S >
n nil I [ i fl I c I fl i M- o " I ' rfi I ' e*' * * '* •*
tli> ili'Iici 1 1 ti’i *i A I 1 I Ic ' II llA ' I Ip
fip'i n o' I'l n ihn c'l i-l o in i ' 1' pi'
triieli '1 If' 1 ' I i' I "-re bil ii tl i * i s'll el* i- i il
iicA It I f i! »ul 'fill i ' Sit *i r I ' c*'i*s*i'e b tl i * *'*
lion I'f 'trim m t! aIc * ' I'li h i i ii 'I O'- lien ' *
" If nil Ic iK 10 'll It n nil aI'i n ir I p of il 'i p i ' *
sr fclio ' inoic cilctti'ili ih in ois e\ps*i iaiiI In
tlnlili n ilie ' ip nir t ni I e nlmn "'cicvl i *' I ' o' e f * ’
if sleimlrlllc iM r tliiMtc i ai il nliitl' tin in' i* ff *
III orllio lot mini r I't ftoni i tnijo \M n lb '
inelhoi's ue in t 'iitsetifnl tis! ini c ihcf o i I'M 1 i
s'fnp of tv iliM r sbonlil 1 r vi'cn
fltncnil rrtalimin
In most cists llic illntss "ill tscnlnill' tit it up
without m> spcciil Ircilintnl but onl) n llit tosi of
sever il "tcls iimbnl ml illness tlnrini "liitli limt llit
piticnts irc i miisincL mil tl in( cr lo llieniscltts iiul
to other pcopk I here is no sneb lliini is shilim
off in lit ick md llitre can bt no doubt 111 n llit inosi
csscntnl thing in Ire ilment is lo tonrinc llit pilitnl lo
his house ind if possible lo keep him in bed for i tl is
' or two I Ins mc-isiirc nlone will ihoil in \n> of the
I
MtKti\ In ihr llmnchl
Ihc uve I'f in c\[ dor ml ot vomh in»\l\ir». lo ii lU v
ihc \ i.iclion I'f llic hrons.!inl \cr\ r u h h\llo''^vl
!\ tr uliiion iinl t wiik I'r cM.n uiUI \\j\ W of tlrn>> In^
been UNCv! Ilic c ilrufs \rc mi lo »i.t in oik of liiuc vvW'
I lu t. in ihc lirsi y ''In tintiniN for c\nnp!>,
ipLi.n.uinhi oiunonintn c irt iumu In hrjt i*om. i!k'
tfiuis <. uoc \onniini »n\I with ihc vonniun iluu i> i fi n
topions txpcvior ihon ihc brondn il imi jhmis I ci k
rtlliNh slimnliUvl lhrou|,li ihc \ ifU'' centre rheir is
t\pttU»i mis IS I ivcil i'll llic issu nplh'n lini ul cnulKil 'v
Jan 13, 1951
ACUTE BRONCHITIS
Bumui
'UDICjO. JOLTlSfcL
S5
Kill still excite secretion in the hronchul mucous glands
The second type of expectorant is exemplified b> potassium
iodide This drug is excreted partnlK by the bronchial
mucous glands and in passing through them stimulates secre
tion This certainly occurs in patients hypersensitive to
iodide but whether there is anv such action in normal indi
viduals is doubtful Drugs in the third croup of expec
torants of which tolu and benzoin are examples are excreted
by the bronchial mucous membrane when by irritation they
ire said to excite secretion drugs in this group also act as
t istric irritants
There is a tendency to divide expestorants into two groups
— stimulant and sedative expectorants — although the only
possible pharmacological effect of in expectorant is to pro
mote secretion At least three different interpretations of
the term stimulant expectorant can be found in the
literature most commonly it means that the expectorant is
one which induces a copious flow of secretion in the early
dry stage of inflammation it may also be applied to
expectorants sucb as squill and ammonium carbonate which
have a sccondaty stimulating effect on the heart and thirdly
It is used to indicate that certain expectorants apparently
stimulate repair of the bronchi il mucous membrme The
term sedative is usually applied to a cough mixture rather
than to a single expectorant drug and indicates that the
mixture contains both vn expectorant to promote flow of
secretion and a drug such is codeine or heroin to allay the
patients cough — a combination which docs not sound com
pletely logical When the word sedative is applied to the
expectorant drug itself it has no clear meanyrig unless it be
thit the drug in being excreted through the bronchial
mucous membrane at once stimulates the glands into activity
and soothes the mucous membrane bv some other property
but IS there any evidence of such activity ’’
Often both stimulating and sedative expectorants arc com
bined in the same mixture reminding one perhaps not
unjustly of the tragi comical classification of Polonius Is
there anv real justification for the use of cxpectormts ’’
Is it really justifiable to flood the system with gastric irritants
in order to treat a cough'’ It will be argued that couch
mixtures ire often effective this is true but is their action
due to anything more than the sedative effect of chlorodync
codeine or heroin t
Secretion from the bronchial glands can be stimulated
effectively by simpler means Copious hot fluids bv mouth
will almost certainly be effective with or without the addi
tion of alkalis the fluid and the heat arc probably the
essential constituents in the many recipes for gruel and also
the varieties of alcoholic hot drinks Inhalation of steam
will also aid secretion often very rapidly It is doubtful
if anv combination of expectorant drugs can produce an
effect comparable with that obtained by these two simp'c
measures
In many cases the mucous glands secrete abundantly and
the problem is to reduce secretion The parasympathetic
system controls secretion from the glands so that atropine
md belladonna bv antaconizinc the parasympathetic will
tend to reduce secretion
In an attempt to alias cough then wc have s*en
that atropine or belladonna will allay spasm and drv
up secretions if excessive a painful drv hacking cough
can he soothed bv steam inhalations and these along
with copious hot drinks will also help to promote
secretion if this is thought necessary In mans cases
cough can be relieved along these lines but when it
is specially persistent or distressing codeine should be
given Svrupus codcinac phosphatis BPC contains
' cr (16 mg 1 of codeine phosphate in I dr (4 ml)
and to an adult 2 dr (S ml ) three times a dav for
several davs is not excessive — the BP do c of codeine
IS ’ to I gr (II to 65 mgl Small doses arc not effec
tive rhere is the thcorc teal objeetion that cough
should not be repress-d when there are secretions to
be coughed up but in a disease such as acute bronchitis
there is no danger except in very debilitated patients
and voting children Linclus codcinac BPC contains
^ gr (8 mg) of codeine phosphate in I dr (4 ml) It
IS really the syrup of codeine diluted with the syrups
of wild cherry and tolu and there is no advantage in
Us use The pill already mentioned containing codeine
phosphate i gr (32 mg ) and extract of belladonna
} gr (16 mg) brings great relief
Chemotherapy
It has been pointed out that a variety of organisms
may be isolated from cases of acute bronchitis — pneumo
COCCI streptococci Mtcrococtu^ calarrhaltv and so on
— and It cannot be claimed that any arc responsible
for the condition Moreover in a disease m which
acute symptoms tend to subside so quickly there is
little chance of bacteriological investigation so that
any treatment aimed at a causal organism must be a
chance affair Nevertheless the use of sulphonamides
or penicillin often seems to prbduCL good results
although It must be emphasized that improvement may
be due to the general treatment of the patient In
children of school age who suffer from recurrent attacks
sulphonamides do sometimes abort the attack if given
at the onset their repeated use requires caution
Penicillin is best given by inhalation if possible an
electric atomizer is the ideal method but there arc avail
able several small plastic inhalers which are satisfactory
these are usually charged with 100 000 units of pcnicil
lin as powder in some and as liquid in others and this
treatment is earned out every three or four hours one
charge being enough for three or four treatments If
injections arc given then the best preparation is a mix
lure of plain jjcnicillin and procaine penicillin and injee
tions need be given onlv once every 12 hours There is
no indication for anv of the newer antibiotics and it
must be emphasized that the use of any anti infective
agent is entirely empirical In most cases confinement
to bed and simple methods of treatment will prove
effective
MEDICAL FIELD UNITS, NIGERIA
THEIR FUNCTIONS AND WORK
nv
J C CHARTRES, BM, B Ch
Mctlical Officer Cnlnnial Mefficnl SerMci
This article may not contribute any new knowledge to
medicine but it is intended to give a picture of a rel i
tivelv new field in the worl of the Co'onial Medical
Service In Nigeria a system of hospitals dispensaries
and their ancillary services has been established and is
being expanded in the larger cities and towns ,.nd i
considerable amount of preventive worl has also been
accomplished again largely m the cities and towns In
the rural areas which are vast and have a population
of some 20 000 000 much remains^ to be done Until
recently the Siaff available consisted of Government or
native administration dispensary attendants and sanitary
irsp~ctors who were given what sujvcrvision was pos
sible bv a medical officer already more or less fuliv
occupied with the curative and preventive worl i
hiv headquarters station The sole cxceptiop s ih_
j\s n i')M
MI
\1 III t P UMIS M(il KU
Slecpin}, ScrMf i (unr nni-i
^lc^^.rl^cil In I iMcr II'). S) 11 .tJmp ' ''
Mtl ctiliu (l')IM -ninth In > p'o r itmtsc ” '
Mir\c\ rcp^il siir\c\t ir) Irt. then
|ioph\h\n inil inli I tl c tlciruuc hn ii the li
2(1 \eii\ hri'tiihl hum in Ir pnin oi imn iirul tmilfnl
I Ills ^rr\ll.c ilihmiih n iiiuIct'i'oS i \ in ti* i!ii*i—
in riir il m n ti'iili icil it\ niniliei !ii ihr ei .* ii
'I.-! pirn nl i\c\\ irriv m the cc il jl i n the n ( mn -
In l‘)t' n pirt o' the 10 .eit e'e -lO,. t - n t'>i* lo
Nijcni I lien nil il ee w e n-n (c pi ! to ije,)
III i)or ctnie iiiw iiul epi !.• iiu i' leu'i on m Uf li 't
Oril III lll\ V ilhi! l’ e i,'ilflii! |e il i ih- i r ir
Is non I It 1 'n n the 'Ich il I le'.' t iit it 1 n i ' i
lercil I iiiitl sit'i till < h'e St p n S li,- i S- \i »
I he inte-itio 1 ni to h ir P pin < i i i n. o 'e 'o'
enh ot the hi e po i Ke* I i.h 1 ! L ' ’ '
hue 1 iiinin il o'luc i nip^ i He 'e it le\ I* \*’( )
IV to 2 I'fen-M III! dll e > cleiVi m' i- ' i '
lithe jiinio ltd'
\1 p Csr It ei h* t 111 hise I le i I il ev* '•t 1 r e
n no I Ihe Ill'll o' opei iti ' i. > c i i' nl i r
l>pe o' con iln mil cIi i te o* i o, i .1 \fii > I i
iVlIeiiic north the Vno'o i ' llo in i " li i ‘ i li
111 nili-»le-i.rl co 1 'itio 1 pi i'll tin 'illnvrce
kill vlumliiu Ilf' I’l leni I’rvnn <• v iit o, A'ei p i
on the III! 1 e uiti, I i, ]i p’llrui ni''i i iv .1 i n i o, i
ind p iril 1 eNo id the e s itp ii i i m t’l too ' i i i ! e
'Uipin. M I iiei nut te eplr i e i' K - tc > >
pttihlenn In ill* oid'c! Mu'd.r licit Iitl'rt in
till Uc vile milt notV 111 111 lid 111 ni > s i vd o c' d
eoitnlri Its note n denfi' It o' In it e nei'
null hn heeii c 'nhh tied ii M’-ol i 1 1 I’lmi e i > t'l
ot I ijin iiid to Itie Ci 1 itie ( in etoii n ii iil < 1 - iiaI-
hclnic 1 the ti' nt il f iin to I'li it d it e 1 -lie Itc- tii-h
Inids of It linen 1 nhcic line tie ds of cittle me p i
lurid I lie Inn lien tiiiil mil t i I > V itti -i 1 1 to Kivet
I’loiiiiits III tile Nif,ct d It to tent ni niiphilii i i
hfc
A prim irv dull of tin units is is lii n oiniii 1 title
suj , ested to issist lov d s ill in loliltolliin I p de lit s
Suite l‘) Ifi lliti hue t'"cn i died o i to ds d mill ' elt > s
liter ttlipsiui feitr sin illpo\ md icret. o pm d (cie
In I‘)i') mil I'^^tl i told of KHttUd i ises of le e’'to
spin d fmr nerc rcpnrled md m llie former \eir tlie
It^mi" linn n i\ trmsfcricd i distiiuc of '■on indcs to
iisist III lilt imcr(iiii> I r msporl i m mill in lire
niid'i it ollntrs c ir mill lorries md I it i ii |oi si df
md Li|iiipnicnl hut mil hi hi till riicr ijile hoise
or on foot Ihe list method if m e iili slut is in ide
md the tret eonipletcd hi mnoiih) lit or m eiih iiioin
mi is proh ihl> the most cn|iii ihic foi those nho hnd
dthihl in Ihe einitilrisidt nhieli ihoiinds m iiiteicsi to
the n ilnre loser
Ihe other prmeipil fuiieliiin of the umis is to ississ
the mcttleiiee mil rilitisi iniporl met of disciscs in tin
ruril popiil ilion md to diiisi nii isuris in iinst Ihosi
ivhicli ire e uisiiii most d im ij e to Ihe pnhlit he illh
As in most pirts tien of the ciiili/id iioild our I non
cite of disi ise inciilenet is f mill md is hisid niiinl)
", P dienl mil out pilnnt niiudmiis I nii
lienee tin be tmtiil onli h> e\ mim ilion of Ihe
■mle popul it.on or of ,ii nliqu He s impli sneh i s.ir
cy IS i escribed here I his inlorni itnni is ol Inst impor
tmec to the economics of , toiinlrj OS of uliost
populition ire pcismt fnrmers proilutiiii
pnm oil cocoi bcnisccO ett
the country depends
. t,iouinlniils
on iihith the iiedlh iil
In I 1 ' • dc
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h s te i let c i h p
SI II • 'o
miml'e o' p
S . I ss'
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1 1 'i, " im- h .1
i o nr 1 o' eh ' ' ''-itt
c I IP irs rill'- ii' e*
111 iilnli d ii 11 c th'ltilciOi lie c\ 1 iiKs e- h
p s 1 lot SI ns o' Il mil del nt,i Itn m no u m
llSls s ll'irs Icp Ovl ukets Cle llll'lSe-l Cudc CO
piiinnts sue II ilioi' ele lli mrs eieh eitd mth
iliteeliiins lot liK'tili'ti I iioln lions md In ill tl
tl ristiiiinl I’nrd ih ssoriKii ol islon Ihcic nc c i fc '
It ( liinl tl, Ihi nisei ol the mo i p oil's. oiii VIi's>cm
It iders Here cvniiiniil in ptii les I chiiul i sp nitcil
ntilsstccii ill ulnll III lies "eic e\ 1 mnnt to icnereil
ihseise hchiiid i siniil it sateen \tlit seemi Ihe n cvh
e il olhecr Ihe p-ople is nt m i leeond n utim lO'ni
nhite iieeinnion md tci leein ition ire iloiic
lilt sceond It iiltiu tooiii lenis to the liriest shelter
oiir to ft 112 2 mettes) loin I his is disnlest into
lihoriloii md treitmenl scetioiis tin litter subdiiidcil
into I elciii uijiilton seelion mil i ihili drc"tni
iiiid ( mir il scelioii I il'or ilori iniislie itioiis in iii es
sirih rcsliicltd to sihil is priiliiibli undir licid eon
dilions Oust hell iiiul Ihcs i m proii triun to tin
liniper to siple teehimiui nnd to the pripiiiition ol
spieiiilins
At 1 iltliilid sunn the louliiie inii'tii ilions iiinK
on ill Utenihiii iri net lilood him It) nimulis st mud
Ihiek him (I itid s or Ciitiiis 1 ) 10 mimiles stool uriin
tested lor ilhuiliuiuri l if positlii the v|Hemien is
Jan 13 19SI
MFDICAL FIELD LNITS NIGERIA
ByjTOIt $7
Mro CAL JOLAVAL
Fio 2 — ProAinccs m Nigeria coAcred bA medical field unitA Aofr — Nijrcna in area is
greater than Prance IlalA and Belgium combined in population greater than populations
of Canada Australia and Nca Zealand combined
centrifuged and examined for red cells and schistosome
o\a haemoglobin — Ihc Sahli method is row replacing
the Talquist
In addition in tho'c with suspected glands sLin lesions
siens or sAniploms gland juice is examined for tnpano-
somes skin snips and nasal smears for Icp’-oss sputum
for tuberculosis and urethral smears for gonococci Red
and Ashitc cell counts cmhrocxfc sedimentation rates
Ide tests and examination of cc'cb osp nal fluid max
also be done On a busx dax si\ microscopes max be
manned continuouslx
In the thcrapx section standardized treatment is pxn
for trspanosomiasis saws sch stosomiasis scabies etc.
and a good deal of general
medical XAork is done Dental
extraction is a popular sideline
and one soon realizes xxhat a
fallacx It IS that the African has
good teeth Apart from the
surxcjLCS for the dax there
IS iistiallj an out patient iiinic of
strangers, niostlx canocmen
and traders and of xillagcrs
from areas not jet surxcjed
The eases seen at these out
patient gatherings are most
xaricd and interesting
At the back of the clearing in
xxhich stands the examination
shelters IS a row of in patient
huts, xxhcrc the scrioiislj ill arc
treated Some arc on sulphon
amides for meningitis or pncii
moma — the latter being surpris
inglj common m tlic cold drj
season — others on penicillin for
ostcomxclitis xxhilc at Cliinkai
xxc had a senes of eases of acute
amoebic djscntcrx xxhich re
quircd emetine under supcrxi
Sion One of the huts is gener
allj reserxed for minor oper
ations performed on a tubular
steel stretcher raised on two
boxes this makes quite a useful
operating table
At the conclusion of a surxex
two reliable dressers remain be
hind to complete the courses of
treatment These arc made as
short as possible to reduce ab
scniccism The intensixe one dax
nco halarsinc or maphar
side treatment of jaws is cfli
cicnt and non toxic trial is
being made of miracil D m
schistosomiasis dailj pent
amidtnc is replacing suramin
( antrjpol ) in trxpanosomia
SIS although all cases still gel
trjparsamidc scabies is effee
tiscls dealt with bj tctmosol
in palm oil
Before starting a surxex a x-arx
ing amount of propaganda and
explanation is required The
medical officer or superintendent mal cs a prcliminarx
propaganda xisit to meet xillagc heads and elders Dur
ing the surxej specimens of xcctors such as tsetse flj,
lice and snails and magnified coloured pictures of trj
panosomes itch mites filaria etc are shown and ex
plained chiefs and elders arc shown the larger parasites
filaria, and schistosome miraadia under the microscope
and a good deal of simple health projxiganda is done
In the near fu ure a section of the unit xxill be stationed
m a special dexclopmcnl area after an intensixe sur-
xex and an attempt wall be made to control the more
common and deadlj endemic diseases in this limited
area
.ss )\s !■«
Ml l)k M f III!) I MIS M<,f f K
ift *■ a f tfcii
llir (lilnlnl Siinr) I liiiliM i
At the ifoti- b) the 1 u'li er 271
P"opU front \ Jill tin inhnn ml frimt t In
liiniii'j (.ommiinilt lvi« tlolirul ttilin e jt d mh-i
were ex ttniiKvl Itie ili mei in w)in,h tiiej %'i > 'd i
pos il'K \u mill ml iliiferciiic in irivil'i e we c
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(I ' •« ), iiiiJ f .I'lre 1(1 1 )
\t tile i e ic i! t xi i ot t> - t!i t I t ( ' i 'e x r
cxmimncd imi'c «'n h ir re on”, i. i, -l’-
hcx-iu'c ot their xlr n htforw ttil Uiu loi »te
7 ft" — 41 1
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probttn s iltrou^Iiotn ili'' iVttfiwi tre nm mp m
SCinil iSU Icp 0 ^X V \ cl C'V ll tin*
with tu pfitSitK I lOx. rl p \
Sfiruni in
fhcfunviioi itttl Use- \Mnl o' c Si t ‘ *
Ijniu *irc t!w CTit rJ ind in'’ r of it r ti iS \ « t \
Mine) of C hml ti Ooin I in P nu- IVowi r ^ r pivrn
lliW pipcT o inMt’rtl \\ iKfi 1 jf 1 t f t» t> nr r i*
'InbcM SctSiTN Si-'*{i'\ [ ^^ 0 J lu 3 \r * tl- \r >
ifvchcvl fio n Hr J I *ts.|rctif ri> ! aI <* ,r jf *
in llic ficlil from Mr J Ci Me ml ifiJ ficM o > i n. r» r v
iiul til tl'id of ll»r H ntic I irM I'lnt
Ut tl PI s M
Ihrifnif f< O ffV I'M rnini A n Ur* fix U .,*.1
t CMcr H M O (lOlSl H Afr /net 7 10
McfcrlLhic J f front / ^ /o / \fr/ //n 41 44*
Dr J Greenwood Wilson nicdu tl ollivcr of hc»tlh I»v
Cirdiff writinj m the December 2‘) issue of ilie \Juftxtro
Journal comments on the c-iunous sun n u)r \silh lU (i
N iccin ition m Itriton Onlv sclctied luhcrudiwis lonUcl
ire inociil licit tnd cvcr> thild so irciinl niusi hue Veer
M intoiix itsltd mil mini he iw {> from ill ris) of liiheaii
tons jnfcclion for tlic six uccts before inoculoion iiui tin
six wccK ifitr I or ihis rcison !oti( udlioriiics luve Ud
'"x* opcnmi ilie nccosirx tcM.knti i
Dlin i ^ ^ 'Cbuiid IX ilicir icsrnitxihihl> Ii
Cmml'^hn’Vi ‘ T V'"''"'" " ‘''""'’titcl b\ th,
mme mn ^ and ilmoxt »n> metlK il nun enn
rus fie bclitvcs it would be much liciter if n f r' ilj i#
' resr„nMt,dd> of’ of t'^U U." ^din..:;^:
- ignnst diphthcrn
Reports of ^Societies
loini'ooi stiuK \t tNstrn 110 N
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t ! ’ ' 1 , • 1 > I ,) » ‘ f f *
t> UtM Iw I ! Mr P ’*(! 1 r ‘
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I I Hsf \n >l e ip w s p d \ d*Sis- 1 s> f* r - ♦ Swf
\ hi h ssoid I , ne a Ich it S fj-i I s^jp -i tr I S * (a
tills h it no’ Kv I I V * , ^ s' vl t u\ d ii N sit ii •'s V e k
f se-dir^ Sof liid 1 I ' ^ ** ! u
ret* »l h > I f rn meP (' t» ; uU«P d n tv frs i var i
s'thcf s »ufi.es
f \ as sh nso to Is of \ itue ir t ^ itiOi tl - ps'stti m ti” t
M c i ( fi n ttomm ihvioid tnsiu ii itnnn-l px>M u'nv fv
ibc ps’sl op I Pivc s ucs on- i» it si fv utten e' were st 'wn
to iKsur in the p\Mmtd4l b'l " later d t dvs m (tor’ xi t
bsbmd tlie tuslici 'ird in llic inrvlnsimun
Hitve ci'fs of Ihjn toxKi MV rnli imtcvl wjiIj T nwbi
ttmcs t>f * I were invesppped llir first pdien: Ind rrnn
rent tti\fs»to\ist»sts mint >cir after {hvf»» dcvlonv Twi
motuhs iftir treitmcnl traser expenments were repeated
the th^robf tissue Ind shrunk md tfie urimrv ewnh n
hvd instxncd sluvwln^ tint the tlnroid fun turn bad b*en
IcnctkuUv ilTctlid the hndims corresponded Iva the
cUmevt unprwcmeni Un sevmm! pitient had a to\K
utcnoini which caused c irdnc failure She did nol tidct
iilc lhu»uru.d 1 was jx^un pre operdneh wdh >ool
eflcti n>c third piiicnt al>s> hut c irdnc future due to
ilijrotoMcosis She too Ind bcnctdesl from trcitment wdli
I nttliou^li It w IS loo V iris to jud^c if the effect wouM
bt pernunent
Jav 13 1951
Correspondence
KnichlsbndRC Plague Uospdil
Sip — At the moment of anting contractors arc bus\ with
cxcasations and stonework at knighi^hridgc Green half
wa> between Harrods stores and the top of Sfoanc Street
A notice exhibited on one of the trees intimates that a
garden is being constructed there for the benefit of
Londoners Tins small triangular open space is cxacllj
opposite the establishment of Messrs Tattersall the mart
for horse sales The tradition connected with if is that on
the site of Tattersall s there existed m ancient limes a
lazar house or leper hospital At the time of the Plague
of London in King Charles Us rcicn this leper hospital
then well outside London was either whollv or partly cmpt>
owing to the fact that lcpros> was i disappearing disease
in Tngland It was accordingly made use of as an emer
gcncy hospital for plague eases from I ondon Most of
the patients died and their corpses were disposed of b>
digcing a hunc pit outside the front door and shovclltnc
them in with quicklime When the pheue died out it was
ordained that this burial pit should remain for ever un
disturbed for fear of starling ofi the epidemic again and
so It has remained unbuilt upon to this present dav After
more than 280 years it is improbable that an\ H pesus
remain in the sod thouch conceivably there may be rats
in Messrs Tattersall s premises h> whom the infection might
be spread if there were any The inhahiianls of knights
bridge can be assured therefore that they run no risk from
the disturbance of this once plague inseminated soil in
any ease the hallow digcincs do not seem to have reached
10 the stratum where the bones may he presumed to exist
—1 am etc
TunbtidEc Wells Hesmv UomNsos
rxcrciscs in Uic Hatli
Sm regret that Sir I conard Hill s letter (December 30
19^0 p 1494) docs not enable me to reconcile my opinion
of Ihc cnergv value of exercise with the statements in his
article (November 18 19^0 p 1153) to which I took cxccp
tion llui since he* expects me to study the pamphlet of
Mr Togna (fie oricinator of the exercises I feel it only
nchl to observe that I would not have ventured to cnUcizc
\n eminent physiologist without prcliminarv carcfyl con
sidcralion of the subject at issue 1 w^s one of the xerv
lirsl to whom this pamphlet was submitted and Mr Togna
himscjf demonstrated his exercises to me eight years aco —
1 am etc
w 1 Aix)irm ADR-sitv'ts
Atvpical Pneumonia
Sir — In the articles (December **0 pp 14S7~<>3)
by Profes ers C H Stuart Hams and S P Bedson no
mention seems to have bc^n made of the fact that some
sufTcrerv from atypical pneumonia thouch non svphilitic
cue positive sNphihtic scrum rcac ions One would have
thoucht the fact vsorth mcnluniac because even now and
then a re-cat su*Tcrcr from this rcspirato v ducasc happens
to have his (O' her) Hood tested for svphilis and the
development or not of p'*».ls of v'om for the suTcrer
depends on vsh'thcr the rredteal ai’c-'daris in the ease
know This cause ot roa specific reactions to ssphihtic s'rwm
tests D fid'*atU 1 succest aUo that the svphihtic scrun
tests micht he a m'^ans of d iTcrcntntmc so-^e of the group
of co-'ditio'^s row classed as atvpical p^-imoma 1 h^vc
bi tied in h- e h-cni sc the d' enp u n bv p o‘’evso' S u^r*
Hams seems ratb-r cV‘'s-l\ s to st eases quo cd
b\ Os-^ord arJ n\s T n a paper read before the Medical
Soci' V fo' t''£ MuJv of Ne^—cal D scases in Ju"- 19-“
cn 1 t-d Th' I ses ^rd tb** I i'^i-.ti''*'s of the Sc'um Tes s
Pirrmt St;
xfforrit. BviL
for Svphilts Referring to atvpical pneumonia in ihu
paper we said
Bui pethapN more mtsleailmg dan the conditions alicads
mentioned is a iransicni bronchopneumonia whu’i apparendv
pucs nsc to vers little consutuiioml duturbancx and mas cause a
positive rcaciion persisting for tw i months or longer PirtKular
attention was dra\ n to this cordiiion b\ ransom (l‘)‘*0 who
reported positive reactions m three undernourished whool
children and oac convalcwcnt from m'^aslcs who were sufTcrmp
from what was described as hilifugal bron hopncumonia in
which radiographs showed a streaky infiltration of the lung 11 c
scrum reactions persuted until the radiographic appc3rank,c had
become normal— that is for a number of weeks ] anconi quoted
Porssman (19^2) as having found only five false positives in 7 711
general clinic case* but three in fix eases of pneumonia and
Poclcls (19t‘') found four false positives m 206 conv descent
meas’es cases f anconi s observations were later confirmed liv
Ifcpghn and Grumbach (1941) and by Jahnel (1941) Ilcrelin
and Grumbach had 18 cas-'s of atypical almost afebrik pneu
monia with the irca) v infiltration mentioned bv 1 anconi and
positive syphilitic serum reactions md Jahnel reported 11 similar
cases Both hts and Heephn and Grumbach s ca es had a hijh
proportion of PfcifTcr s influcnra hacilli in the sputum and their
^cra strongly ''gglutmatcd this organism ft seems possib'c ih ii
Pfeiffers bacilh may l>c capable of provoling pseudo svplnhtn.
scrum reactions in patients with labile scrum
Both Fanconi s and Hegehn and Grumbach s articles arc
illustrated by radiographs — I am etc
Ijondonswt I w Hsrbisos
Rtrtfrsns
r*ncom O (I9VM SrA-r/ mrd Wsch €6 S21
! omman 3 (1932) Acti Mtd D^od dm Set A tS i (ref
Fancom)
Hamson L W andOvmead T H- (1943) Brit J >fnfr Dlt 1# lOS
Uegcim R and Onjmbach X (1941) 5rA**«'i mfd \\seh 7t S7g
Jahne) I (t94l> Mm H tcAr SO 10^
rocUU W (1933) A /n Utclr 12 <31
Trcafmenl of Lumbar Disk Lexronx
Sm— We must all be grateful to Dr James Cvriix
(December 23 19^0 p 1434) for bringing some sort of
light and order to clanfy our ideas about lumbar disk
lesions I hope his remarks on the importance of lumbar
lordosis will be widely noted and followed Here 1 just
want to mention one way m which thev art at present
often flagranllv flouted
1 do not now frequent large hospitals but I find th it
surgeons still have a habit of directing that where a patient
IS bcinc anaesthetized for a laparotomy the hands should
be placed underneath the buttocks This reverses the
normal lumbar curve under the anaesthetic the spinal
muscles relax ind so the lumbar spmc goes into marled
flexion This IS I believe the rcison that numbers of
patients after operation — and especially when thev pet horrt
where they speaV more freely than in hospital— complain
of backache more than anyihinc cise It is of course still
more common after the hihoiomv position
Physiolocicallv 1 think that the right place for the irms
IS across the chest or if this gels in the way of the surgeon
thev should be crossed in the operation gown and allowed
or made to drop bad towards the sides in such a wav that
the town exens pressure on the thorax In p'actre this is
easy to arrance Su gcons seem invanablv to say that this
will impede brcathinc but the fact is that inspiration is
caused bv active rruscaib- action whrh can casiK lift th-
wc»'’ht of the arms while expiration is almost entirely
pa sivc so the weight of the arrrs on the ell'll tends to
make It more cfTc'tive and helps to count-Tact the cxlr«
incHcicrcv of expiration caused by relaxation und'*r the
anaesthetic The ret result is to imp'ovc and not to inter
fere With re piration A snail cushion should be placed
urd'T the lumbar spine to prevent it flattening under th'*
anaeslbc ic
1 cannot chim to be an exp'^ on this subject bu I have
vet to b-ar anv refuUtion of the simp!* r^'chanical and
phvsiolca cal pnmples on wh eh nv remn Is arc bj *d c r
to see anv v.ilhn!r'*ss to carm out the si-'’pb chan"es ir
te^briau* which tbev su*''cs* — 1 am c*c
CORRESPONDENCi:
\\ N Irs)
‘>0 J\s 1'
c ntuu M'O' !>i Ht I
fi/ - 1
^ ti t- i
SlK — tn lin Kvcf I \tjutc D riWr2'
p 1 cmpfji'* C' (f c ' U ^ \ 't^ \ "Ia
p»’i’;.c *ur». Maupn^jHr Ot t '‘i “itc i.\ >’n t‘ ii
jcrertl ifKtKt* tftJ «(» i p ictuc v( (^caAjC ■»♦ r f* ?
I0'» J'cs i'f til imo ''iK I '• n mil if ' <■
lOtfiiifc imJcf ihn linii rihni t n ^ i * t’ ifj 4 P I h
tol|j\ lrUfvl’^tll nfiif Ipit p'ci i’ > ifrif- fi
Im luwl ttlir u ii \\ \> icriiin ti imj ^ l^f t i i'll
noMbU ilioijspo Mrtv rcn i(n c* 1
tu'ns U<vMr f ill li»t b j nnl% c I ' I to %♦ oc
i.ir ill ilw, e\ct> d^s i. m b* '* ^ i’'» l'
of ill'- cir 'ri\ct> - i I til til A> 1^1 I t cii I *J t
like j ru'ni\ i\ liic i.oMtn o'^po !cii’o»» il fj * f o ll
piOilu t»o 1 o' 1 ri ti mI MfiVrri im I) b i-c pj I ** U
i iti \N c t. M Otl" if 1 if i ' t li^ iM t» ’i <■ * *''1
luk't ird '>lt ip'' I ' { ?i P / t* ^ fil -» I t » ll
f i f'lit t* c /» P' I ^ i'* J ll '* cf» r
mii^h I It' ». ll - Ir% cl V * il r fiT if f ’10 a - >
pr R ilioncr m \ ol "nc « 1 b»i f‘> i»
fill f Ri {I * r I '''f ti
tut iVt li » I'l 1 C I Ci » ti t t * '
tt fc 1 ' 1 tl’ if i t < ».4 1
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t" V t il iM, h I t{ ’ r 1 > I ' I
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to Ou.t I i‘ - t V ! ^ '
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if “ b tti ti tf I I o I 1 i'ii ’V
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iSjtll t (1» V ^clioll i fi ll - tj 'b t III I *l <i *
if 4 bitilcfil ffi 1 1 1 h 1 lI'C I f « i r 1 *- c I
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Ji»ini m mipiil iiion bn I cen an! 'till li 4 *» r •‘I »i
cnipjfici! «>tuii\ ihouib tbc ll co > tcnittncU ul ti cl \
J MenneU (/oif r '/<ff iri/'/ //Off 'ol ^ 1 p > inhiin-* l| c i \.vt
fence of III inirn iiiivulir tlticoi n ti \ct me t p o'
irtictiiir iirfivci opposed t«’ <’nc iiioil cii vioiild 'cem to
iccoiini for most of ihe phcnofTic n iit-t \s»ih m tbo ficM
! ini etc
/< Hof tt N I! } isiuoo >
SjR~In his inlcroiiiii ifiulc iDcccinKf 2' p
11*11) Dr J C>ni\ olTcr^ locful uImvc on lunv to 4%OHi
the conililion iml how to prvvcni fc\.nrfcn c
Suricon*. *ir iltcm\c(\i,\ ionKliinci ftlTcttcd I hsvc I o! %uc
illjct of <tfinci conMifcied l>) \n onfiopictli Miij-con t»i hoc
Ikcii probibU dm lo i doV pioini it n 'tml mm> nlM k> if
lumlnfo winch I now bclicic were noi piitliucd bs lo al chiUm-
or otficr Mich cnii'c^ hnl weic iiNo of dok iirnni ylotlowuu
\onic inoniln olf dni) I j 01 Midden lw|nJc^ of nil mn k. of
tumtnjo dnnn) iht tour c of out of lli-' Imi opcfttinn uIirIi
I ptrforincd tin opcntion hsiiOj mote linn an lunir urn! wlmh
incMnlily iniohed n tonsufcrnhlc dej ttc of >pitnl flexion I lux
impkisint octiiffcncc nude me Mopctl dj »i ifu ifinmrtf r<»do fo
had caused lilt pirinl Intkviud iloplucincnt of n initlro
pniposus I w IS tliotoinhl) tilmncd for I fnicd ilni 11 furtlicr
period of incipicil) w is nbonl 10 bepn j decided lo ir> Ibe
ciTccl of extension of ific spmc by wtijbi A folded lowcl sv is
phetd on die lop of a door and bool mj no finfcrv osci ctii
1 hnn^ for a few mniules and there iftcr tompleicd die opci luoii
without further trouble fhis imdc mt rtHctt low u cfnl ii
would he (f every sur{ con s drcssini room Ind m n a ibicc fool
icnpth of liorirontnl bar At the end of a nuirrnni s opciaimi
I short swin^ from tins nw^hl wUl pivc n disk which luid hctomr
pirtidjy compressed a tiunct to rtadjusi itstif I womicT if
On I r considers dnt such a simple meet of ttiinpnHiu miKbi
hnd favour widi mdustml medical ofliccrs Snitt the shut of
my experience 1 have been careful wlitn doini similar operations
to piuse from umc to time and to stand in a Scry trctl posidon
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/-’aloe > (
d
p lilt 1 % '
d - ) .1 '
J V
app et»4 fvt
tv ^I' r* s »
--v
nuos I m
<
r ^
D 'Sj t s>'’vs '
1 ' t’ f i i* xi *
t> r -T i*s p * 'i
{ 4 «» ’ ' * I I f
i' a / S * » J ' -'•p V
J - ♦ d 1 'i b *
r - * i-. » r -"f- -
, ,1 p m 1" t*- t -V
,» J ^ *i ff a- a
4 f d p -1 e
J. » if » ^ • 44 * •*
t * t* - - 1 f f *•
- J d- ^p-s - ei ^
4 V It d - , r ts i
'i r f « c • si
V n t X s - lo I * fn
's V* « ' t'^'i V 14 * I r*
I (» ^ t V l t ^
Sir - U ( ans aid ' ai ’ar at *t tn c- s » * <d
irt ll c da> (4 s!-\ SOI (*' d f tdi ' * aix t-s* ' *ap^s
I tilt S 4 » ll ip*nird i s ll it s VI fvr> » ' l' si^rd -a** e w vs
tv iiin''n cd in S erdvf J w’ ' m \* *id 'lafv
l‘U** Dll ifiulu vxcie r Ibi'ci tn t* c ibiM //r
Soir/i' I'Jt; II .r-l We < rrc <t»fp (’ vl f ef* c
I Ole I> I'clci O Ic Mils tv’Tt cnl ft> c iK? U
p |V l> dial no one '*> Dr bn j icf), cd lo assess t ^
psilcniialdics of this niclh wt f*'r vl i ’ sim d p C'vW e v
t ifdu d nt r mliti \ We rcv illcd for eimuil c\ini‘'v
lii»n tio\ vMvtv ibo c vsl 0 t nc in si < 0 n tl tai* t ' 'i d
pitUitc bol lU additton ill those v>ho j ne a bis on siivvcs
livc s*I previous ibcuiuali it fe tis* o' bcbcviii. lb >
hui he 111 di case It vs n bopctl in ibis vs ty with d lutni
lUum of intonvenicpec lo ensure lie ilcicstion o' csrdia
II tuutu ildics IP p iticnis un iw ue *'f ill eviMint- 1 can if u'p
Old) the rcldionsbip between the ruhofrtfb 'ind citn >1
lindUH'' O’ lelcv vni Us Oi live ills uili le Tlic nts d
tonitno)! t Mists of rci ill on svsvsuni of \ iiv ai noiu’ni'i'C'
were jcncrd tudnu cnliivetdcid pionunciKc of the phi
lUonirv uicr> sir ii> lileiuni. of die left bciil i oivi-r
pro ninenl touu unfolihnK of die aotli brouieniP) vf
die btsc of di- belli itui tlexirovardi 1 of dice die
c stumoucs’ vvctc tiidus cnlirjinienl jts'ntinirKC of ibc
puUnonm vnciv slnvlovv oul ptomineme of die tonio
or the ll*?l/s roulint i ri\ ptsluns of dn chest in tiie
pcrunl under review K77 wjib no luslorv of licul disc we
vveic cMinuncd !>iciijse »>f one 01 oilier of dusc Idler i n\
11 1951
CORRESPONDCNCC
ibnormiliiics and of these »»-♦ were found to ha\c orginiw
vnUc disease and 8 conccnttal heart di<''n<c a higher ina
dence than the 5 cases of organic mKc disease and 1 of
congenital heart disease found in the I uerpool sursev On
the other hand the hichcr incidence m our inscsiigation
ma> he inHacnccd In the fact (hat n hivtors of previous
rheumatic infection was also taken into account Indeed
of the 44 eases of organic valve dne sc 23 gave such a
histor> We hive considered cirdiolonical ease finding b>
mass miniature ndiographv to be sufitc!cntl> worth while
to continue with this part of the service —We ire etc
Atrx MsarvN
rh ro AS Rons
Fniotions and the Skin *
Sir — The cnlcrn for the <clcction of patients with skin
disorders for Ircitmcnt bv abrcictivc techniques (December
9 p 1300) would serve cqinlU well for the selection of
patients for inv ps>chiatric trcitmcnt The skin conditions
described bv Dr H J Shorvon and his colleagues were
m inifcst itions of psjchosoin iiic illness and called for treat
ment bv normal ps>chntric methods The f ict that abrcic
live lc''hniqucs were used is neither here nor there Ccrtainlv
there IS so far no inoicalion for the treatment of psvcho
logically determined skin disorders bv i specific form of
psjchntnc therapy
\brcaclivc technique is n form of psvclioil ernpv and not
a minrcuvrc divorced from nircoanihsis Patients should
not be ibrcictcd mcrciv in the hope of relieving tlicm of
tension Tension is relieved hv giving them an opportunit>
of expressing their emotions Thev then become more
capable of discussing their problems md viewing them
objcctiNcI) 'sarco anilvsis is a useful method of giininc a
more rapid insight into personahtv and the possible factors
underlying a neurosis In 1941 I discussed (l^rca 1941
I ^07) the m in ipcmcnt of cvccsstvc ibrcaction in the course
of n ireo an dvsis md 1 do not vet ulvocatc uncontrolled dis
eh irpe of emotional tension Shonon and his colleagues
on the other hind cmplnsi/c the degree of excitement pro
difccd under drugs is the item of greatest thcrapcutit value
md thev endeavour to excite their patients even bevond
the naturil and sponl menus rclc^ise of inhibitions which
occurs during n irco an ilvsis An opportunitv to let olT steam
will relieve tension md relief of tension may help i
v irielv of skin conditions but bstmi, benefit can be brought
ihoui onlv bv the scientific applicition of ibrcaUion
Dchbcralclv to distort events m the patients past hislorv
to produce f re Iter excitement or anger ipp-ars to rrc to be
verv unjustifiable and possiMv dmgerotis SIio^k tactics
m IV have to b idopIcJ m ome eases but sureU should not
be idvocilcd as a routine practice
I »m surprised ibit sine of the cases referred to in
Di ShorvonN iriitlc were trcitcd bv prolonccd and deep
sed ition befoic tbc ibrcactivc method was ittcmptcd llcivs
edition I inv iTiabU toxic in sorre degree and as a treat
ment is uMiallv LonlniT dnted m psvcbologi al skin
di order Tbs esc histone vscrc n ost inicrcstirc but
dinonstfiicd lie valti- if rarso analvsis r”orc cTcUivclj
tin” lb It of ibre ctivc technique — I •'m c
{ - u Ti t IN Sn s.o»
Containers for Svringc Sicnii/ation
Su, Tlic te ill iti'»a vnng- bv dn hca! as c-o**
mended b\ lb MKC Report t f 1*3-2 is stu! in th s c< t nt v
tire na bs.1 ‘ f ».b i c 'slKn v ’*''di ions p-nnit In ri '’“ir**
t ho ~ al vriP'* sc v i c tl b r -“st pro^’em i t^-* o'
pa kin. ssTir‘~c f Ta! al " d ^nb » •*’ nt* t re L,m
It SO”! M" thi-.y*'' V e V q V " t ' 1 c V r-
'IRC Pr^ t ~ s f
- A--" - o is- I
, , ra- ^ \ i-r w — b * i
si ~ p— •‘-V 1 _ ^
K c
Tb write has m dc an extensive trial of pa Irn" vair cs in
gLss tubes rnadc to si7c so tl a each si/e of s>Tjn'*'* is con an-M
wuhm Its libc retained bv a cotton wool plug and witli n gv rd
over Its nor/le i ach s urge after u c is rcpl tcvl iris
conl-incr and rctarncvl bv its co ten wool p u-* It is t! is
prelected until rtturned for scninnp
The disadvantages of tins m thosl arc
1 Tlie cscc sue cos of tubes made to order
2 Co ton wool IS pcncf Il> a nui an^e wlicrc ssnnces arc
concerned Strands of the fibre can cau c j~.mmtnp of a wcfl
fitting plunger and can prevent the atr tig! i fit of a ncal c 1 1 i^v
if used more thin a few tim'*s create a cloi d of fine dust o i
disturbance as shown bv blood films nade at tbc time Tl s
arc a small but ccntinuous item of cost
3 All containers made of glass arc liallc to break
These objections arc met bv the u c of the extruded aliimiriuin
containers illustrated here
Fach svringc is retained bv millciblL clips fixed to a thin
piugc sheet of ilummuim which is a sliding fit m the bixlv
oi the box A rccdlc can be fitted before removing the
svnncc from the clips so
providing a stand until
required Thts js a grcit
idv mlagc on in macsthctic
trolley
There tv no cotton wool
The lid of the box is seded
b> »-dhcsi\c tape which cm
bs. quicklv wrapped round
the middle of the box after
II c retaining the contents
and indicating thit they hivc
been used The boxes not being cvlirdnc*!! cannot roll
thev ire much lighter than gl iss tubes of a comp ir iMc si/e
thev arc pncticallv irdestructible md thev ire compact
being little lonccr than the sire of syringe for which thev
ire designed The abihiv to sterihre a syringe with needle
fitted IS s,icririccd but this is myuay only salisfjctory on
mctil nozzles md Icives the operator without a choice of
needle Where drv heat stcriliz tlion is not ivailiblc the e
containers can be used in an autoclave For this purpose
holes arc drilled is in the illustration and can be afterwards
closed by turning the lid round
While these boxes arc verv much cheaper than glass tubes
made to order they cost t htilc more thm those of standard
siz'^s but this IS outweighed by their idvanlaecs ard Ih"
fict that thev do not brctk Thev arc m ide m four sr/cs
for I and 2 ml rrl 10 rrl and 20 ml syringes Tbes'*
boxes can be obuined from Messrs I dw irds Surguril
Supplies I td 8 Mo timer Street I ondon W J - I am ct
HcrT.(ir3t2 Hen G A VlMfllfV'.s
Amollicsia of llic Ne«I)oni
SfR - I un nnnl i"tcrc^tcd in Dr G JacI on Fees',
escell-nl article (fi'cemh-r I9'0 p I..19I B> i nc
in;: the tclalivc Icn; ihs id Inche-i insohed howescr I
fe-I that ht ficiire of i for the inf.n' re o'ipcc i
exce M\e Pcferrir- to Mac—tosh a-d Mu •'in s //nrer
fnr the ■iri rs I cii\! 117) followin., iR- crr'rir'cnl uhlch
confirms F o-u lie s law th- an horn luUe the l-n-th o'
th" tl he insohed nrJ n deuM; tic fow fair- th-
ascra'-c pi" h' lo ''dii cation I'-n'-Ih in th" adiill _s ~ in
1 10 cm t and in the inf r 2 in ('em) tlm oi Id n n'lf
tl- res 'tarcc hi c in tie lat -r s t-_-l -n ii - hr
It* Oefh till 1 i-h IS 1 'I p> h less nl r-ire f -ii c than
tl , r._| — I _m c c
r> * -1 a si D r Fi I s
Baclenn in Jce-crcam
Si- -Vi .n-o a mn (D ee-T- 2 1'<'0 p 1 .Iir-'-
I , jw- j ,, „ _ , o' I- p -- -
"s- '-—•'cji-ir I's.- w c I
ss - a— 1“. -d I- S . -n V e. ' t* — w t - i -- p _ p i
woes- p — -i-np-p 1-1^— pr >
IS _ ' c ' — -eJ r ’ c‘ ' < r' -
/
Ja 13 19‘^i
CORRCSPONDCNCC
y*TTr At J'* V t
much comfort There ob\ on !\ i dcfcwt m the \virint.
of the hlinkcl vjth the rc<-ull hn ll c p ^hortin^
Ihrourh T hcaw bbnVct \^hich dirc^. h in corijci uith
the pirl*; ifTcctcd and \ hich ua^ al'-o touching the iron
framc\\ork of the bed
The ravh cleared comr’clcl> nl cn Ih" electric blanket \\ is
banished — 1 am etc
Uonnuth Tins PsFJ IS^ov
I onj; Unihilicnl Cord
Sir — A fev. months auo 1 iticndcd i pat cni m her third
confinement FNcr>lh!np was norma! The umbilical cord
measured from its root in the pbeent to the bab\ s na\e1
4 ft 8 in (K2 cm) There was nc twist complctelv
round the bods up oscr the front of the bods oscr the
shoulder under the same nxill then up and twice round the
ncc^ md a pood bit to spire llsrssards Jcllctt s \1i(U\ifcr\
•sa>s that the cord can be is sh rt as fisc inches and as lone
as fisc feet just in a pcncnl wa\ 1 think that this ease must
be more or less a record — I am cis
Sjilrara n Cr If S''Jia Anrrt a ^ ^1 Writs
Hclpint* the Ncssls Hhnd
Sir — M i> ssc as idn mt ti itors rcspcctiscls of
St Dunstan s and the National Institute for the Blind dnvs
the attention of those of sour rcidcr who ma> be asked
for ads ICC hs piticnts losing their sight to the proper course
ncssls blinded people should follow if !he> ssash to tike full
adsantape of the Blind \\clfarc Scrsiccs'’
If a persons loss of sight Ins been caused or aepns itcd
h> ssar scrsicc (includinp cisti defence) he or she should
pet in touch SMtli St Dunstan s 191 Marsicbonc Road
I ondon N ^\ I which is responsible for suvh ci'cs
Rcspon'ibilii> for ill those whose loss of sight is not
attributable to ssar scrsitc— that is the cisilian blind — is
borne b> the local authonties and th- lo^al aolunlar>
agencies for the blind in co opcntion with the National
Institute for the Blind Ncwlj blinded civilians should
therefore pel m touch with the loc.il Blind Welfare
Aulhonlv or should there 1 c anv doubt about the identilv
of that bodv with the Nilional JnsiiUite for the Blind
224 Great Portland Street W 1 which phdh provides
applicints with an> information or advice thev ma> require
—We arc etc \\ Mutw
V-retin St f>jr sr •
I C Come AN
S'-rrctanr-Cr-'^al
1 PiJ n VV I ''ail *5 Mn j f-r the V
n'Kl!
POINTS moM imTRS
I nus-ual Prrsentitlon
D A J Msnion M o I m d4s Is1 of No th bisi) wn cs
l> n a rccT't bbo ir n a p mpara w’ i h '■rrei ed < r-i-^
fo w-tfil was vTusc ! I > hm a ton of fcsioa o'" - f«y a| t eaJ
II :t p osovi to be dee to Pe rti-bt fc Cw.rm to s i*'-
iM oat und r ll cMn t v -'d down tl c bs tl c co d wbchw ^
t M nsu-d ft c^rm "''d r-* V. Al I rPi tic rirM 1 -"d w-as
h I w a*' ‘ N-1 nJ tl c 1 ft car i''C ba k o' lb" ^ard r a 1 c
no k d'-sc-*'! o' :h" 1" d w s bw b^ d p cso" ed
pn dt I i '
Mffca \c*minUir3tor '
n n D J iivs-is He " I wri "s We "-m n I sc n *’
- w‘ r' j u I 1 --C « ^ o 3 0 ^
"• J- I i" D C K Mt rds * .
^ f "J s'* f t*--*.e , g
^ ^ -J T k tr** t " i "'•n I — • *'
I I w J * c w ' CT re--’" ' I> J
^ -.4 » s - -r I — —v ^ ' -s r " *. '
Obituary
G R GlRDlISTONt. DM IRCS
Mr G R Girdicetone wlio ph\cd a Icidinr prrt in
Itic idv^ncciTii-nl of orlhopicdn. .iirfcr\ in iIiia cotmliA
dica on December '^0 need 69 Acarv
Gjthornc Robert Girdlci.lonc \\ is born in Ovford in
ISSI his father ""IS Canon R R Girdicsionc of Christ
Church Oxford F rom Charlcrhoiise he went on to
Ness College Oxford in I at St Thomas s Ilos[ilil
sshcrc he continued his mcdicil cdiieilion h" ss is
Uni\crsit> Scholar lie qiialilied MB BCliir in 19 IS
and after scrxine as casiialls odiccr and house surjson
at St Thomas s he ssent to Ossscstrs as i pirliKi in i
surgical practice and there he imnicJiatcls came under
the influence of Sir
Robert Jones ssho rcgii
laris xisitcd the hospii il
for crippled children
sshich Dame \cncs Hunt
had established at Has
cnurch It ssas as Sir
Roberts liculcnint tint
he plascd such an impor
tant part in the founding
of the Ccntril Council for
the Care of Cripples In
1911 Girdlcstonc becim-
a I clloss of the Ros il
College of Surgeons and
not lone after the out
breal of the first ssorld
ss ir he seas appointed ssliile i captain in the R A M C
to take charge of a unit for the treatment of b me and
jo(nt injuries ii Oxford Those fess huts it Hcidinelon
sscrc the origin of Hi. ssorld f imoiis Wingfield Morris
Orthopaedic Hospital It ssas Gird'estoncs enlhiisiism
md skill as a siirecon sshicti ssere IirgcK responsible fo
Lord Nulficld s immcnscls p actical inicrcst in pro
moling this hospital No less saluahlc thin the hospi
lal Itself ssas the ssstem of clinics sshich lint ed it In
lossns and sillagcs in Oxfordshire Uuckngh imshirc
md Ben shire Girdlcstonc Irascllcd ssidcls to explain
the adsantages of this method of org ini/ing onhopaccie
care and it was after a xisit to South \fric Ihii 1 ord
NulTield established m or hopaedic Inut there similar
to the trust he formed for I’lc dcsclopm-nt of o iho
paedic sso I m Great Britain and Norllm n Ireland
Though the Wingfield Morns Hospii i! ssas the main
interest m Girdlcsioncs life he bailt up a li ge o Iho
paedic pr 1 C ICC •>n i was on the siafT of mms hospiLls
in-IuJng the Padcliffc Infirmirs the king Tdw rd \ II
Hospiti! at Windsor the Ro il Bii S irgi nshirc Ho pi
lal I \slcsbirs the Sascrmlc Hosptil t Marl
bis ou"h nJ the Ro^.rl Jo"~s mJ A""'" H mt Ho*
pi'-'I nt Os sestr The Sm-n'-in Orllioo cdic \<'m
tion cicctcsi him ■> co rc'po''Ji"e r"e'nh— Jn I'lsT he
w„s ip-va a ed to ^c fi s o'! ' of o thopi--J ;s to K
cst *'hsS d in this co-"'' t^" Ni Ti Id p o ts or hip o'
o l''‘'p "di-s " Oxfo d He d J "o re"" 1 n p'o'c
'o-c bsscse 'o' h* rcsmnej m 19-0 -r-' b - s"-
co~ L n to tl c LM-S -"d 'n ihe M:"i ' oi Ih-
s o"s In P-d ‘-e s-’s e'ec d Pres d of ' . P i i
Or \ss.->-jj,iaa He a o -■ r~ " - t i-
s and t'X " sals -d ^ s ba^', 7 1 /
Ii "" -"d Jn " a-s p^S’ ish"J in I'l- 1
r—
94 J\s n 19 M
>\c irt ifiikhlcJ lo A H (> iof ikr
followinj (pprcxiitii'n \Micic\ri m t!ic vo Iil (> th«'
p\a!ii. Mit^cr> Is pr all fi) llic mine ss( Ctuslte • me
Is kninsii He \s i\ p I'minetil m llie stmU , <"il' "J
pioiKers sslid <!i\ct( pul iinpuivn! -im! j spsi'm 'K m
tircil Diiliin iinl the Di'tiimu' i Ih- pit pV itil
nicthoils of the prime oitmito o! ihi • as’ il
ssicitse ssliuli Ills ti ins^otiii- I tie livsi o* m niti f
ihli ihforincsl imt ni) ireil hrititiii 1 'ui Hi '."e nl
teieher icul ceTiitp'e ss is Si Iso’s't Jm s s ! 'e
iiicthoils he stiishcil III eo'hl >f i!i > I m! r l he st n the
sun Is i! pitliiei I'l i 'i ni of ihKto's u, O sis i> 'ts h
Iso he o\ rs) to I) It I \t'i s Hull st • - I , i t v
Itisshiirsli p oM.leit hull ssith in nr! ins' \ ,0 ’n*
Ik is is esc itu 11 s tii sfs ile I u'l rtf in Os'o il 1 a i
In no 111" Ills onls the 1111, vi tint u's s ' tl it 1
h irneil there in the tre itii r o. i ip, ' lu i' 1 * 1
ils<' the pull is' ileso'io 1 111 "'I'e 1 1 r o* 1 u iml
ssitli sshislt US liter >c rs Ir t npiiei' aI! his j » is
He hmt slf ss is i lorn sn j. ii SsiU stroi s s i ise
h inils mil 111 iiir ii III line 1 u ' i tii'o 1*1' *' • e i'
the lisiii| s' 1 lures hr S' is fnri ’un '' csii v ^
4 ils mil (Vffseli! il so It i"i ssill esj ti u aU f - ' n
ol iiiciiKine ri ile 1"' f ep liu i 1 u i o’ \ <1 ’>
levi to sslu h h- I ml' imru m’ i’ si 1 'i' ' >
Hu s lllsll I'ei! I'eKlip Mil (i( o 1 n-' o,s A 1
nictho's ssteniitis shn it oh 's m < t n f n'
impsnt ml nn'o,Mph oi lut'r »ii'i s o' ll " i r cs
jsuil Chi t' e o ) iiii/ itM 1 o* oil ipics'i '» II
hospitil uni sh Us mil o i the s[ ro itt s'u ' o s'l t ' •
he ilorie hr po' c 11 <1 is'o'e so itimn'i ti 1 1' *'
peril ip 111 till I p»s! o' o Oil, ir Ik 11 t si’ s' his
iTiosI ni issisc ml o ii III ll so itiO iim 1 1 ; 11 eo sr
i/cil s\stcni of sitclhte shills rtoun ' ' r li e sn'
from tile sctiti 0 In 'pit 0 ssh sh he sies’cl ii t* e
Hxfotil ret lull ssOl lorn re nun the 1 1 nlfl on oils
hit otlhoptcilis hill fo ill forms of psiiln* re Mini
ssrsices I mil iiv I isi. oser the sontr ictii, \-sis st e
sstiiis to cc the W in( lielil (lossim liV.r n n s Ms' in I
hiitt util sprs ulirti Us heihit uiiliic isr fuilir < i!
further itilo the sotinlies It ss is itu huu h'fo e I otil
Niilli 111 fsll timlcr Ills spell im! } I'e the sp’emlnl u.l
ssliich triiisfornisil the tcmiotit) hulnieiUs of the
ninsisen tsscnlics into the f im nis \S ui} lich! Morris
Hospit 0 of to ll IS A further resent Innetistion his
sssursil Curilkstons House for nnns scus his home
on the ontsl irts of the hospit il ns i s ilii ihle tcsnlenti tl
tnnsxs iiul i pcirnuicnt mcmori il to his ntnie
O !C G s nluis snlcif sliirislcr ( iiiiril him
mmiiiisrihls fricmls Hs ss i 1 ‘>iperb lolfir ssl o
nifht sssll Inss hten iiiiitciir sli mijiion if he liul
not liiicl hslter lliini s to ilo mil he escclleil nt ill
t miss rsiiiiiriiu 1 Issii tst mil issm its sonttol On
Ins profession ll siils hs lies mic 111 iIik sonrss I’rcsuUnl
of (lit Ortliop Kilts Assosiition WItn foul Nulhslils
trcil nittfis ll htrisfislion s uik to Osfonl in the
ninstccii Ihirliss hs ss is the oiils possihls slioisi loi
the cli iir of orthopi ilis Mir(tr> ssliisli hs iissupinl
svilh much dislinstioii lUil ifisr some ss irs of msts is
int str un lit found it rKttssir> to rtiiirii to the lik
of tlinit ll priclict and hospitil orj ini/ ition sshiili In
loved iiid of sshich lit hid mult siith i brilh ml SUttl
His loss ns 1 ptrson is irrtpirihlt hut Ins (,') ss irs of
life tuivc been very full of ithicstmcnl mil nrll lour
romun mcxiniplc mil cndurmi, inniicntt
H J S wrilts Girdltsloncs lift ss is Iht Wiiij litlil
Morns Hospilnl His desolion to it dss irftd ill liis
other ichitvtmtnts uulhismmy 1 dtiils I his itiiiroiis
{ft > ‘If iM’ I iir ‘ t t; ’ > J - V '*
U| h P* '■t ^ t t -H-' 1 o' ' ’ ♦ If’'
•1*11 k hr *’ \ iPiJ h‘ < fc- J 'r o "
\ t\*t\ Ifl I'tc- 't *t r o' M - f < “v J*' !' r- 1 -’^ j
Cl* S f t ' 1 I i h * '* 1 1 > ' s! < ^
i' - i'* * 5 r o If c ! if r o' (rf Ci*
%\ U\ fit V ' t » c > r _ 4 *
tt s- it 'i t i * I f ^ Ji i * ” ^ 1
ffT J ^ * y < - t C »
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on t IS life thus <1 h ti W h-n ss, l st 11 v s’ s' ''s
ifirr ms irris si m I n Isiiil -sin ost tsisUe s its po I s
cxtrildnl to iiK Ins protesliSs aril's fro ihl rt'" '''
Osford iiiil ss itsliei! ittentisels sU iiss 'Icp-. imti! iu
s iss me liVmi rools in this sonniis sm! ns the lu"pt'l
Ik hill foninl d Hiis mtmssts fiicnsUhip sn I dnh
sonlisl J iss me the opjnirtiinils sd dososcime- o sv of
tin most s\tt lordin irs tvtsonnhlies t'f ths nsssh d
ssiirld ol to ihs Hs ss is i mm id sshom ms sss ntrs
It ms tinn iimhi he prinid \s in ill nun ssl red
udiiis his I K It t|udiliis sniiKil to te ho onls sihcnl
dtfisls Its Ills simpluilv he filkil to impress ssipst
(isi ll id' sissis mil hs Ills iiU'ik Sts snd rstirini ihspsS"
tion he iKsri ill iiiKd Ihs risoi mlion to S'hish hisirsst
iktds siiiiikd him His nu'sksis Ills ipiMtsisI to the
slid hv his isliisiiij to hiss i nicmoml ssfiKs ikitMitsd
to Inns Hisdiisslnis iinl iilim ptirposs mil 'inssrils
loiilhsr ssilh Ills iiisipisits tor ihs'imnl itissis sssn 1
sonrss of sunsrini lo him iiid sonisliiiu s to olhiis Hut
ill Ihsss aitiihulis ssiit hXs sm ill urns implnnlid us '
Jan 13 1951
OBlTLAR'i
r i"
1 1-- II
foldtn hcirt Here Iij In'! suc*iitli ->1111 Jic oiit-.!andmr
fcitiirc of In'! pcfAonalitj
Girdlcslonc Ini been an example of a in n who Incd
to loiL He loved God and all I’nl coma from Him
He loved hiv conntrj hiv fn ndv ho raticnlv hia pro
fciiion and Ins hovpila! Av a son maiion of all his
olhcr prcit ifTeclionv he convcnlr ilcd hiv icndcincss on
hii wife Im llic faiihfiil compmioa of Ins life The
iUcim of crippled ind infirm childtea who tim> under
hii care for more than fort> vears wck is their children
and he nursed them with the tuid me v of i father
I ovc brinfi forth love and '’Ivo fiuit In 1919 the paces
of this Joun al were honour id w ilii th- public ition of an
article on llic Cure of (-npp'cd thildrcn sipncd b>
Sir Robert Jones and G R Gudieston'’ Ihc c an
almost Utopian plan for t!u piivcii ion trcatm-nl md
cdiic ilion of children snflcni 1 from orthopaedic condi
tions was expounded b\ il e master and (he \ounp
reformer Now Hurts >ca s ntcr the Wingfield Morns
Orthopaedic Hospital and he orthopaedic otfaniralion
of (he Oxford Region stan ' is a listinc monument to
the nicmois of the genius wlio made Ulop a a rcalitv
He imparled to this hospital so much of his love that he
Icav cs behind m n w hat is 1 now n as a W mglicUl
spirit Hie on!) recemp nvc for which he sought vv is
Ihc affection of his patients md of those who surrounded
him and in that he w s imph rewarded We, his
inlmialc friends have sufTcred an irrcpaiable loss Ins
patients love a great comforter and England a greil
social reformer
SirllMHM CHEMLL NCR CVO IRCS
One of the few rcmainini p-rsonal linls with Lister is
brolen bv the death on J imnr) 2 of Sir Leniha!
Cheallc who had been identilied with Kinns College
Hospitjl— 1 isitr s 1 oadon hospital for well over half
a ccnliirv When he wav iirgicd reeivlrar at Nines
from I'txu onwards he cam- in o close avso'iation with
I ister who oeeiipicd the chair of surgerv at the Colteec
until 1S93 ind in f ct Cheallc nssivcd him in th* bsl
operation that he perform-d
Gcori c I enllnl Cheallc was horn in ItfS He
received biv edmation at Merchant Tavlorv School
and at Rings College and Hospital vjuahfvmg in
mcdieinc in l'''>' He vnv alrcadv a m'mb-r of the
Medied So iciv of Kings Co’l-ge in Ihc sevvioa I'lSS-C
and bv ivs‘> he h’d b%oaae vice president He held a
number of posts suckcssivciv in his pwa hosp lai vvhrli
wav then in the neighbourhood of the Strand — d'rnaa
vtraiO I'f an'tomv house si rg*o 1 louse phvsci n
surgical rc-istrar an) from 1S92 to 1X9-. demaas.ra
to of surf al palha 1 o"i Hu appo Pi" -a as ’ssistanl
Mirge''a at Kiags dated f ora and la I9'''> Ihc
sear b- eh iircd U c 5 K t ds 1 » was ni dc fu’l
suicoa at tc ch-r o' s ug „! gi i s’sgc
Il 're 'v daw o' ll " P'- Wa h- wc-'% o_I to
Su th \(i 1 wi h h V fo ra- c*" e' S r W a ton Ch'v--
i|' e 1 a IS s g'oa w’ o-i I s e' had v- o gv- { ci"a <; a
'Tit b h o' t' em cc'ivic- a g ra ' om
kmgs s 'i- S , 1 ' W V ' 'xi 0*a"' v v 3pp-> a 'd
ia {j (p '-v be vvas p — o-*J
m s' sp ‘-s csc'c' f' CJ~r —I r -d_! ->- • fp„-
c ,i'"s 1 - > « s r 'eta -S'*'- o' t'-' B ' I" t*"
r I s-s - sn o' Isil'-lS te gave t is — v -es to I''p
K ov.i V sv t’- '-'I o' I g aa rc’ ad™ a!
-r. ) SS s -- ii- »"d la - has'- '! s'- p S<L -g l' *
C)’’ -s 1 c - g w" S t " c~i o t" w_t ’■e w.
K C P H- co~ - :-d 'o •- -V V'3~, o b 2
<is
m mN-r o' the Co"su!lalivc Ilaard of th* Koval Nava!
Medical ServisC an) of th- Admi alt Dst itlTitil
Committee Sir 1 ea''i 1 Clicall ai o li • v in 1 'im
pirt in I'lC creation ol i medtv 1 b ans'i of i' c Nav it
I cigi c
On hiv rilitrn from nav 1 di ties Ins wo s Sa Km v
Collc-c Hosgili! vv a rc‘un -d an) m I'O’ h I >'
sen OT vurgeo i and oa of the Iccturcis o 1 vu i c v He
retired from llie nlive still m 1'>’0 and w is tpjo itcd
con iiltiHs Slug on to the
hopitil ind cniciitns Ice
tiUer oa thnisil sur, rv
I I th ri die 1 ! s,.lio il
Amo ![ ot'i r ippoinl
mcniv which h- h id he'd
were those of siirjcon to
the I lorcOsL Ni, him ilc
Hospitil md coasiUini
surgeon to the Hoi[ it d
for Pii ilvsis tnd I pilcpsv
the Stirrev Disfxnsaiv md
the S verm As an I Bur
ford cottage hovpit ils He
had v!so hvtvl the vv'het
of pTesldeal of the See
tion of Sing rv of the
Pov ll Sociclv of Mcdi
cm- Honoms were bestowed on him In lb- llihin
and ! rcncli Ciovernii ents bv the form 1 he " is
niae'e an Oflieer of the Cii md < rovv of llalv nd bv
the latter Chevalier 0 ! the Eeeioii of Ho loiir Ihc
Anicriem College of Siiri eons nude him an Mo lorurv
I cllovv in 19^2 In the previous vrur he hid received
the Wal) cr Prirc from the Rov d Collcg- of Surgeons
evf En-lard for lus wort, on Ihc palho'og) and thcra
p-ulics of cancer
To Ihc end of his life I ivler vv is hiv great hero though
lus p-rsonit asso-ntioa with him had been limited to
th- last few vears of I ister s rciga at Kings He spohe
often of 1 ister V devotion to work and of hiv eoiulcv)
to all who avvivltd him and vvav fond of (elhnf ho v to
Lister the op-riimg theatre was a temple of wl ase
s inctil) he would permit no infrimem-nt O-c o-ci
smn he rev ill-d was wh-n lister brilhantl) perfo m-d
an ope alion m 12 «Csonds -nd when th- onlookers
b ole into a sub't -d cheer he ti tned round and a d
Gen lem-n rememh— wh-rc vnu arc O - out anJ
ing cha-ac c ivtic of Lister which Cheat'- «ltosc S' ccev
fills to emulate wav criipj'o iv aveuraev a-d atlcntioa
to det 111 He OPS- to d Cf -atle that he co 1 d no rcvall
eve having riidc an I-3C..U ate st !-- a-al th it th- c
was no h ag he 1 ad eve said o wri i-a wl c'il-*i''-d
to ic ra-
il was 1 IV -< •» latioa wilh I is — nd V a’srm Cl —
that rav- Ch-„l!- tus sp-vn1 1 - - c‘ mg til o'a-v He
wav m o' I' n ca e'l 1 o' i-ves i-a ors !_ Iv la
h V c-iccr h- rc^o-ai/ed the impo-iapce o' cii ting an i
exaa !- -g 5 - 1 a— o' an afre ed o gia and fa this
par -u'.r p pm- h* d-v -d th- larg, r-cdone
o~ I"— av -tvia -d w 'h h s nam- This r-- ‘oJ of
n c -a ma 1 ,.,-g' -d la pirti-i a- to ca c ro-"a of
t' - teas ca w-ich s»b -ct la cat the ana aith
D *l Cu e t— w-o e 3 t-itKaa'i. Tu a,/?- o' trr
B r*i H- o w 0 c l''- s-c ioa c- al a — ' oa a-'*
due ses o' I*-- fc ea*' la S - Ja-e- V o- 5 S nr 'c'
Pc-'-i I i-d t’ - a ca v-gg a ica la C-o ee s
5 I p— r' — r H- -as o-e c' I-e c- 1 -<t la r ve
n— •e' r"s o' tCw’-ji 2 - 1 oxta to f,t — j w a aOj-Jv
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m (fiiffal ptitlKP 111 Irn'i ff ii in lit \t *f t i i
fit'll in will It tear lir ('*’ tin- ‘ lli i(ij'tt i o' j
llPillli willi c filil Alt ' 1 ' tint li 1 ^ 1 r r »t'! ' ' In i
4clf in jftirtil pncliti* O tir o' li nilif ' sj , ' n!
ilicnlt ivn in llir oUl At -iilffii llnj n i » -t tlin'i
illeiultntc lt> ntfiliv. il aloilfnl tonipn* o tl **»
nol only tiiil lo Hlfinl oiil pili-ni tlin t t il nl’O ti i fil
p i!icnt4 in llicit mm lunnrt S< 'ik* linii. llif'c tttrr I i in
III lon[ OMKitlion Wiilti llic M'rtilctii Um il lilttinita
l)t lilt appointment at a' Mini in le-illiclit! l! n tlic
rico ni/cil tieppini lour lo llir I’ono ii till 1 itrr
lie t'cc line a titt int ptiwici in and iii I'll'* full pliytlvnn
mil lecliitcr in cima il iticilaine lo Itic Unitiitll>
I in illv on lilt telirenienl from the liotpilil in I'H' lie
\t IV lippoinletl toiittillint pti>vli.i in Al one ima lie iKo
held tin. potl of oliviciMc plittaiin i| llie Mitcinilt
llospiiil At an early pciiod in lilt tmer lie het line
alt itlitd lo llic iniitciii medic i depirimenl of the
Utiitcrvily lirvl at iiwivi iiit iitd liter it kctiinr lo itic
I lie Proftvtor C ivti Me la i line inliictled iit Itic
prohtemv of di ihciet mid coll diot, tied ttilli the lite
Dr John Ucnnie of tlic nitiird liitlort dtp irliiienl
cirrtini out tome important rctcuchcs on itie leliolopy
of this disorder Rennie hid pointed out ih n in i.crliin
of the leltotican fishes die islands of I itiperlians formed
t/
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I 4*1 1 1 I'll*? 31 d I * I 411 i' l' 1 t' ' * I “ d I' f* In
id’ll 1 fio 1 I’>‘l to Mir 'e ti4t a ( r K cif It
<« - t! 'led i! < o 1 ' 1 JI tilt o' At» dr* ii'"
fe rr ' op 'ft In ii t’ * diOi > la' i o' D p dt I t i '* n
O' not* o' III* n 401 ' ino ft t 'i *1 Cir * I' 1
t t t e f o e p o I Itii 1 l' e I I D dep re n’ *i ih*
I'mtettilt lO ifei evl npv' l liti l m l"J‘* “ft h'lia tfiSuU
111 01 e tsh 1 for t 1 ti in\ erih i 't sent hid hcea a
dcto’id ind hn it 'i o' hit dn i nn’ef
I'e Inpt lie tt it Ihe IstI tiittiti"' of a peaerilii'a in
will li it w It piiitih'c fo a mill lo Ctsndu i the iid o’ <
diilirt of 1 i *net d p u till mer an I at Ihe tan c lim* be
in oiiltiardinp leivhtr in a medical t'lu'ol and lisdit
mint of hit former tliulcntt will loot hat with prali
tilde on all diet learned from him and wdl lemcn I ff hit
lonriett hit dipmis hit Inin mills and die esamp'c of
one who londiaicd all hit work on the hdhest citiaal
slindirdt Me ts Mittited h\ liitvtalow and two tons, 10
whom imali stmpidis it exiended — A G A
\V C S wnles Ihe passinp of Dr lliomas I rater
It not onlt die pattmp of a well hcloted f imiU dixior
hill die psstini of in cia in i diet il prat lice so fir as die
Nortli of Scot! ind is concerned Dr f rater s cl unit
lo Hilda il fame were liul on tert wale and solid
Jan !3, 1951
OBITUARY
BwrmH
McotcytL Joormal
97
foimtiilions He «as a fine example to the medical )oiith
U the Aberdeen Dispensarj of the combination of the
bedside manner par cxcclhmc and the shrewd clinical
obscmtion that stamped him through all his wide prac
ticc Alwnjs Ihinhing of the patient—carlj or late, far
or near, poor or rich — if the needs of the ease were
there so was he Ncser did ans phjsician spend him
self more unselfishlj for his pjtienis WTienescr an
operation was performed on anv ot them he made it his
business to be there so lint he would know exaeth
what was present and whit was done in each ease In
this wa> he kept a ser> close watch and ward oscr all
his cases and was thus ible to assess more fiillj future
deielopmcnts from past experiences Tor many years
he enjoyed a fine rcpiitii on as an accoucheur and hts
help was prized by many eollcigucs as well as by the
patients It was diflicuii to see how he could stand up
to so much night work when his daily xistling lists sscre
so long partii;ulafl\ when one remembers how generous
he was at any cal! — no hurried in and out for him In
all his professional dealings he was most correct and
proper — indeed, cxen fastidious by modern standards —
but he clung to etiquette and enjosed great kudos for
that In the earlier days his soicc was heard at medical
fcsijsc occasions in song ind on more serious occasions
in speeches that were alwass well prepared and carefully
delixered in the Asquithian manner He was a soracious
reader of all sorts of literature and kept himself informed
on all matters of current medical and general interest
while spending all day and often part of the night on
hts daily task his patients He was a student of the art
and craft of prescribing and therapeutics and elegance
added to his courtesy at the bedside made him indeed
the belosed phisieian no trouble was too much — m
fact he wiped the word trouble out of his dictionary
Quiet dignity and efficiency inspiring confidence delight
ful easy friendliness and courtesy abounding combined
to make him a perfect gentle knight and his memory
will be long cherished by the laily and by the profession
he did so much to adorn
HERBCRT STANLEY FRENCH, C V O , C B E
DM FRCP
Dr Herbert French formerly physician to His Majesty s
Household died m London on January 1 at the age
of 75 He was at Ihc time of his death consulting
physician to Guy s Hospitil to Queen Alexandras Mill
lary Hospital and to the Royal Hospital at Chelsea
Herbert Stanley French was born in Newcastle
upon Tyne where his father was a merchant He was
cdiic iit-d at Dulwich College and Christ Church Oxford,
10 which he gamed an open scholarship ft was at
Christ Church that he met the son of Sir James Sawyer,
a physician of Birmingham svhose daughter Amy he
married m 1904 After obtaining a first class m the
National Science School he came to Guys Hospital with
a university scholarship m 1S98 and there won the
Bcaney Scholarship the Beancy prize for pathology and
the Gillson Scholarship of the Society of Apothecaries
He gradiHtcd BM BCh in 1900 and after holding
the post of house physician at Guys he held a Rad-
cliffe Travelling Fellowship from 1902 to 1904 the
year he proceeded DM In 1906 he was appointci/
assistant phvsicnn to Guys Hospital and m 1917 full
physician He v\as admitted FRCP in 1907 and was
Goulstoman Lecturer m 1908 choosing as his subject
The Medical Diseases ot Pregnant Women For
many years he was physician to HM Household
During the first world war he served as honorary
lieutenant colonel in the R A M C and was appointed
consultant to a large military hospital at Aldershot He
also became consultant physician to Ihe Queen Alex
andra Military Hospital Millbank the Royal Hospital
Chelsea the Radium Institute, the Enfield Hospital and
the Surrey Dispensary He was made a C BE in 1919
and a C V O in 1930 In 1928 he was president of the
Harxcian Society Early m hts career he examined m
medicine for the Society of Apothecaries ind later for
the University of Oxford and the Royal College of
Physicians He was the author of many articles in
journals and textbooks but in (his held he achieved
most fame as editor of An JiuUx of Dtfjcrcnnal Diag
nous of Mtnn Sxmplomt which first appeared in 1912
He retired from professional life in 1929 when still in
active middle age and devoted himself to his property
in Surrey where he turned with whole hearted cnihu
siasm to fruit farming and cider and chutney making
His first wife died m 1946, and in 1948 he married Nora
widow of Edward McDonald He leaves a widow, son
and daughter
A H D writes Trench appeared never to hive any
doubts about his decisions or the goal for which he was
making His determination to succeed was evident in
his student days, and as he passed through the successive
phases of house physician and registrar to assistant
physician his quite extnordmary power of intense
industry became more and more apparent As 'a house
physician he started collecting notes, sketches and photo
graphs of eases of interest thus providing the core of
the book which was later to make him famous Soon
after election to the staff at Guy s he developed pulmo
nary tuberculosis and went for some months to Corn
wall where he devoted his time to sailing and hshtng
Within a few months he was back at work, clearlv
recovering m spite of the most exiguous treatment as
judged by modern standards He delighted m later
years to demonstrate his health and strength in spile
as he said, of 16 positive sputa’
He was a most impressive teacher partly because of
hts love of the dramatic and of simile pirtly because
of the emphasis he would lay on the practical side of
therapeutics He was just as ready to teach the best
way to insert a bed pan as he was to discuss the latest
development of Ihc focal sepsis theory His post
mortem demonstrations and reports were a model of
lucidity and an example to those who followed him
His clinical lectures always secured him a picked
theatre where he would without apparent effort speak
and illustrate on the blackboard for an hour without
notes and without hesitation He prided himself on
a teutonic mcticulousness which made it possible for
him to edit An liidix of Difjtnniiii! Diagnosis of
Main Symptoms The index alone took a year to com
plctc and entailed the making of over half a million
entries Most of this work was done when travelling
in his car to consultations for which he w I's in ever-
growing demand His other most important contribu
tion to medicine was a description of influcrfza as it
appeared m the 1918 pandemic During these years he
continued to extend the scope of his clinical experience
while fostering an ever increasing consulting practice,
which by the end of the war was probibly one of the
largest in the kingdom Hts health was now robust and
he was able to enjoy a ful! social life m addition to
his professional activities By 1920 the strain on liis
98 Jan }3, 1951
OBITUARY
BulTIiH
Aiedical Journal
capacity for work had reached fabulous proportions, and
he had come to the stage of success when not only doc-
tors but also laymen would ask for his help He was
a strict observer of etiquette in relation to professional
work and never allowed the patient to consult him with-
out the knowledge 'of the general practitioner
' With 1 characteristically dramatic gesture he retired
at the age of 55, sold his house and everything in it,
even to his stethoscope, and retreated to Newdigatc in
Surrey Here he was able to enjoy, the delights of
country life and holidays on his jacht He had taken
his master s certificate a'nd grasped with his usual clanty
of mind the intricacies of navigation His health and
strength seemed imperishable ' The death of his wife
a few years ago was a great blow to him, but he faced
this with the same indomitable courage which he showed
in his final illness His happiness was restored when he
married again some two years ago, but a painful and
fatal illness struck him last autumn, and he ended his
days in the hospital he loved and served so well
GEORGE C CATHCART, M D
Dr George Clark Cathcart,~who died in a nursing-home
at Broadstairs on January 4 in his 9Ist year, practised
as an ear nose and throat specialist for many years
in Upper Wimpole Street and m his day had one of the
best consulting practices in the West End of London
Cathcart belonged to an old Edinburgh family, his
elder brother Charles being a well known teacher of
surgery "at Edinburgh, and he went to school at Edin-
burgh Academy and Loretto He graduated M A at
Edinburgh in 1883, and thereafter went to Australia and
back in a sailing ship and was a pupil at Naples of
Scarfali, one of the, last teachers of the old Italian bel
ennta in order to cure, a stammer He returned to
Edinburgh to study medicine, graduating M B , C M
in 1891 and proceeding to M D in 1908 He came to
London as a resident at the Children s Hospital, Great
Ormond Street, as did many Edinburgh graduates^ of
those days, and then became resident house-surgeon at
the old London Throat Hospital (later amalgamated
with the Throat Hospital, Golden Square), to which
he was later appointed honorary surgeon After the
amalgamation he became consulting surgeon to the
Throat Hospital Golden Square, and he was also con
suiting laryngologist to Mount Vernon Hospital, ir^ the
days when it was still a hospital for tuberculosis
During and after the first world war he was a member
of the Special Aural Board of the Ministry of Pensions
In his earlier days Dr Cathcart was greatly interested
in problems of the voice, and at that time his contribu-
tions to medical literature were mainly on such subjects
,as voice production, stammering and tonsillectomy It
was directly because of this interest that in 1894 be
founded the famous Promenade Concerts at the Queen s
Hall London He insisted that in order to prevent
vocal strain the orchestral instruments should be tuned
to French pitch and not to the higher concert pitch, as
was then 'usual , and he also insisted that his young
friend and discovery, Henry Wood, should be the
conductor of the series of concerts Then a young
bachelor of independent means, Cathcart was quite con-
tent in order to prove his thesis to lose several thousand
pounds in starting the concerts, and when they began
to pay their way he gave place to others In his later
days he became more and more interested in deafness
and Its prevention He revised and largely re wrote his
friend Hunter Tods Diseases of the Ear m 1926, and
in 1931 published a small book. The Treatment of
Chronic Deafness which went into a second edition
Not infrequently the victim of his own kind heart he
was also ever sympathetic towards the unorthodox in
medicine— homoeopathy, osteopathy, the electropbonotde
method of Zund Burguet He had always a current
favourite among such methods and their practitioners
He was an ardent freemason, having been a Past Master
of the University of Edinburgh Lodge and a member of
Grand Lodge
Dr Cathcart never married, but he had many nieces
and other relatives to whom he was devoted, and there
can have been few men more beloved by 'more friends
in every walk of life — R S S
Dr Alma Percv Ford who from 1919 devoted his life
to the care of patients suffering from tubSrcuIosis in the
county of Hertford died suddenly on December 18 19^0 at
tha age of 60 Born at Spalding Lincolnshire he was the
son of Alderman A Ford J P After leaving the Mercers
School he sUwiied medicine at the London Hospital where
he qualified in 1914 On the outbreak of the first w'orld war
he volunteered for service in the R A M C and was sent to
France in August 1914 where he served until he was-
demobilized early in 1919 He look the D P H in 1920 and
after a short period as assistant school medical officer in
Huddersfield he was appointed tuberculosis officer m Herl
fordshire and also deputy county medical officer He
became the driving force behind the great development of
the tuberculosis service in the count) and his work was
recognized in his appointmeni as one of the two representa
tives 'of the British Medical Association on the Joint
Tuberculosis Council At the time of his death he was
honorary treasurer of the Council a position which he had
held for many years At the inception of the National
Health Service Ford was chief clinical tuberculosis officer m
Hertfordshire and medical superintendent of Ware Park
Sanatorium After July 1948 he became a consultant chest
physician and physician superintendent of Ware Park Sana
torium Always a keen member of the British Medical
Association he was honorary secretary of the East Herts
Division from 1931 until 1938 and was chairman of the
Division from 1939 until 1944 guiding the members through
the difficult war years with oulstandinc clarity of jiidgmenl
and tact None of his friends and colleagues in the Join!
Tuberculosis Council and British Medical Association will
forget his forthright personahtj radiating from his powerful
well built figure His interests were wide — at one time he
was captain of the London Hospital association football
team he held a lifelong passion for cricket he was a keen
golfer holding the Ledward Cup for several years and he
was an active supporter of the Amateur Dramatic Society of
Hertford Ford contributed a number of papers lo medical
journals on various aspects of the treatment of tuberculosis
and was joint author with the late Dr Hyslop Thomson of -
Tuberculosis of the Lungs published in 1927 His loss will
be widely felt not only by his med cal and nursing colleagues,
and his many friends but by innumerable patients all over
the country who have known hts sympathy and djnamic
energy In 1915 he married Lilla Robeson who with their
two daughters survives him — C P C
The Services
The London Gazette has announced the following awards
Bar to Air Force Cross— Wing Commander H P K Smiin.
^ Air Force Cross — Squadron Leader J S Homtt RAF
Jan 13, 1951
UNIVERSITIES AND COLLEGES
Bkttish
^^£PlCJU. JOLWta
99
Universities and Colleges
UNIN'ERSITY OF OXFORD
In Convocation on January 16 it will be proposed to confer the
honorary degree of DCL on the Rl Hon Sir Godfrey Marun
Huegms PC CH KCMG FRCS Pnmc Minister of
Southern Rhodesia
UNIVCRSin OF SHEFFIELD
The Council of (he University has decided that the new Hall of
Residence for Men which is being erccied m OaUioIme Road
shall be mmed Stephenson HaJi m honour of members of that
family who ha\e served the University and its forerunners in
successive generations
Dr D E Price has been appointed Honorary Lecturer in
Pathology
EPIDEMIOLOGICAL NOTES
Smallpox at Brigfatoa
to noon on January 9 there were 17 patients bebeved
to be suffenn^j from smallpox in Brighton county borough
or tn the immediate vicinity of these cases Two have died
and the diagnosis in three was stilJ in doubt During the
previous week the infection had been confined to the two
oncinal foci — the laundry to which the clothing of the
initial case an R A F officer was «:em and the hospital,
in which the second case was not diagnosed for 10 days
Among the laundry employees there have been six cases
Two of these worked at a receiving branch and the
remainder in the mam estibhshment The laundry has
now stopped work The hospital is in quarantine and
members of its staff admitted to the smallpox hospital
consist of five nurses and one domestic AH these penons
were employed on the ward to which the second case was
ndmitted and nursed m a cubicle ''
The vaccinal state of the nursing and domestic staff at
the infectious disease hospital was unsatisfactory 27 out
of 113 never having been vaccinated On investigatioo
among nurses and domestics attached to the ward con
cerned it was found that seven were unvacemated Of
these three had very httle contact with the patient and
did not get the disease All the remainder had intimate
contact and one died and three are in a serious condi
tion The other two nurses now in the smallpox hospital
have a good vaccinal history and in their cases there is
still some doubt about the diagnosis
Pohomjelitis
Poliomyelitis notifications in the concluding week of 1950
were paralytic 36 (38) non paralyltc 17 (15) total 53
(53) The figures for the previous week are in parentheses
The tcfial uncorrected notifications for 1950 are 8 696 com
pared with 9 195 in 1947 2 379 m 1948 and 6 857 in 1949
There were no notifications in the week under review
from 35 couniv areas and in the remainder notifications
were more or less evenly distributed, no county notifying
more than four
The incidence of pohomyelilis in 1950 after correction of
notifications is hardly likely to be much less than that in
1947 when it was 4{ times greater than in any previous
year since compulsory notifications began m 1912
Influenza
The statistics given below for England and Wales and
the Great Towns do not indicate any senous epidemic of
influenza up to the end of the year Any increases m
pneumonia casts and deaths and influenza deaths are not
much more than norma! for the time of year A mild
form of influenza but of a very infectious type, has been
epidemic in the north east of the country, including
Newcastle upon Tyne and elsewhere in parts of Lanca-
shire including Liverpool and in Birkenhead (Cheshire)
Bui in these districts the epidemic has probably passed
its peak Serological investigations have shown that the
epidemic in Tyneside is due to virus A it may be identical
with that m the Scandinavian outbreaks — virus A pome
The results of further laboratory investigations are awaited
There is at present no evidence of spread of the epidemic
lo the Midlands and South But in many areas there arc
local outbreaks of a mild disease with symptoms not unlike
those of influenza they have not yet been shown to be
due to an influenza virus
There is serological evidence that in Sardinia cases of
influenza have been due to virus B
The following cases of and deaths from pneumonia and
influenza have been reported in the Great Towns
1
28/10
*nt
11/11
!i8/11
25/11
2/12
9/12
16 / 12 I
'23/12
! 30/12
Poeumoflia i
\
1 .147
i
Cams I
236
1 281
261
313
302
t 282
! 374
' 364
502
Deatbs {
|4I
198 j
177
lliS
207
1 198
! '‘36
: 21>9
351
383
Destbs i
17
19 j
20
16 j
24
28
34
33
54 j
102
Totals from the first week of the year in the Great Towns
compared with the preceding two years are as follows
1948
1949
1950
Fceomooia
16 452
17416
19 043
Deaths
10 337
11 786
10 461
Iztflumra
I S59
Deaths ,
608
3 090
The following Tabic shows notifications of pneumonia—'
pnmary and influenzal — in England and Wales
28/10
n/11
18/11
25/11
2/12
9/12 i
I6/I2'23/I2;
30/13
PneufDcrala
43S
TsT'
465
558
490 1
497 j
573
684 i
647 1
962
Coirespondjng
week 1949
303
4I9
1
534
667
710 j
7.5 j
734 j
676 j
1
634 j
842
The following cities and large towns had the largest
numbers of pneumonia notifications in the week ending
December 30 1950 London 64 Birmingham 38 Sunder
land 32 Sheffield 24 Manchester 23, Liverpool IS Gates
head J5 Salford J4 Newtaslle 14
The following weekly claims have been made on the
Ministry of National Insurance Week ending October 28
1950 127245 November 4 144 446 November 11 148 497
November 18 147 415 November 25 145 783 December 2
1420n December 9 141 403 December 16 128842
December 23 87 277 (four days only)
Regavmal totals of influenza deaths in the Great Towns in
the week ending December 30 1950 were Greater London
(included in London and South east) 22 Northern 34 East
and West Ridings 4 North weslern 30 North Midland I,
Midland 6 Eastern I London and South east 24, Soulheni
2, South western 3, Wales 1 , total 106
Infectious Diseases
A large fall occurred in the number of notifications of
most infectious diseases in England and Wales during the
week ending December 23 1950 The falls included
whooping-cough 768 scarlet fever 242 dysentery 190, and
acute poliomyelitis 54 The only large exception to ‘the
general decline was a rise of 105 in the notifications of
measles The notifications of acute poliomyelitis were 7
fewer than in the corresponding week of 1947 and 18 fewer
than tn J949 One third of the cases of acute poliomyelitis
were notified m London and the adjacent counties during
the week
100 Jan. 13, 1951
EPIDEMIOLOGY SECTION
Bwttish ,
Medical Journal
During the 5Ist md 52nd weeTs of 1950 54 and 102
deaths were attributed to influenza in the Great Towns of
England and Wales These are about twice the numbers
registered dining the corresponding weeks of recent years
Notifications of inlluenza usually rise to a maximum towards
the end of the first quarter, and it is possible that the
present outbreak will be larger than those that have occurred
in the last few years The disease is now prevalent chiefly
in the northern cities
^ rijsenterj
The notifications of dysentery were 190 fewer than in
the preceding week, but with this exception they were the
highest ever recorded The chief features of the returns
during the week were large falls in Leicestershire 138 and
Lancashire 8(9 and rises in Staffordshire 49 and Middlesex 29
The largest returns were Lancashire 173 (Southport CB
53 Oldham C B 25, Salford C B 20, Manchester C B 20)
Leicestershire 101 (Leicester CB 89), Yorkshire West
Riding 136 (Earby U D 58 Bradford CB 19 Sheffield
C B 14) Staffordshire 74 (Stoke on Trent C B 44 Stafford
M B 11 Cheadic R D 10) Middlesex 69 (Edmonton M B
54) london 60 (Poplar 13 Islington 12) Shropshire 48
(Shrewsbury M B 26 Whitchurch U D 12) Warwickshire
34 (Birmincham CB 30) Cheshire 29 (Wirral R D 8)
Essex 26 (Romford M B 15 West Ham C B 9) Glamorgan
shire 23 Monmouthshire 23 (Newport C B 9) Suney 2_
(Esher U D 9) Yorkshire North Riding 17 (M^dles
brough CB 17) Northumberland 16 (Glendale RD 9)
Devonshire 16 (Exeter CB 10) Durharn 15, Norfolk 15
(Mitford and Launditch R D 15) Kent 13 Somersetshire
12 Sussex 11 Soulh'impton 10 Northamptonshire 10^
(Kettering MB 9), Gloucestershire 10
^ Week Ending December 30
The notifications of infectious diseases in England and
Wales during the week included scarlet fever 1 02 ,
whooping cough 3 690 diphtheria 41 measles ^^8, acute
pneumonia 962 acute poliomyelitis 53
tvohoid fever 6 Four cases of smallpox mending nv^o
iSorVed cases were notified In the Gregt Towns the
number of deaths from influenza was 102 ^
Quarterly Returns for Scotland
The birth rate during the third quarter of 1950 was 17 3
gf rl .M9« ,S',rbVi.w ih,
^/corresponding disfaLf D
mfluenza 9 to mMStes and 9 to whooping cough, 38 deaths
tt^etrtegistered from acute poliomyelitis
Industrial Accidents and Diseases
According to the M.nntry of Lcb^^r the
1950) the number of ^^^/^“'’'^‘’/.dents m the course of
United Kingdom ,950 was 151 compared
their employment in N°y "1 ^er 1950 and 123 (revised
with 112 (revised fieure) m Ortober
i« »
deaths of 11 tsaote" o'Ofo I diseases were reported
i.’SirhTr'-lof
:«k%K.rop?g£S htr , 0,1 P, and
chrome ulceration 10 total
' - ' No 51
INFECTIOUS DISEASES AND VITAL STATISTICS
We pnnt below a Summary of Infectious Diseases and Vital
Statistics in the British Isles during the week ended December 23
Figures of Principal Nouliable Uiseases for the week and those for the corre
Wales (London included) (b)
(d)Eire (e) Northern Ireland
1 recorded under e ich h/eciious
England and Wales (including
London) (b) London (administrative county) (c)The 16 principal towns in
Scotland (d) The 13 pnncipal towns Jn Eire (e) The 10 principal towns m
Northern Ireland . .
A dash — denotes no cases a blank space denotes disease not notifiable or
no return avathble
Disease
1950 |l
949 (CorrespondmgWeck
(a)
(W|
(0 1 (d) 1
(e)
(a)
(b)
(c)
(d)
(e)
Meningococcal mfee
tion
Deaths
3!
3
1
18
1
I
-
/
28
10
i
-
I
Diphtheria
Deaths
•46
2
13
5
I
81
15
25
1
3
Dysentery
Deaths
1 024
60
148
4
221
16
67
!
4
Encephalitis acute
Deaths
6
1
—
—
—
1
\
-
—
—
ErvsipeHs
Deaths
28
"5
4
-
28
6
3
Infective enteritis or
diarrhoea under
2 vears
Deaths
22
1
7
9
it
27
1
1
27
4
2
Measles*
Dcaths+
14 328
1556
1
197
120
2
79
I 684
32
A
23
47
107
I
Ophthalmia neona
torum
Deaths
37
1
9
!
1
35
1
2
7
—
i
Paratyphoid foer
Deaths
3
—
H
J
5
2(B)
Pneumonia influen
zol
Deaths (from in
fluenra)^
Pneumonia primary
Deaths
Poliomyelitis acute
Deaths! j
Puerperal fever
Deaths
Puerperal pyrcxiall
Deaths
^7
54
42
4
IZ
5
2
1
634'
27
29
5
7
2
4'
2
7
2
350
69
301
•J
296
44
296
22
iJ!
9
53
3
6
1
4
3
— 1
81
5
8
2
' 2
1
— 1
3
1
74
10
5
1
72
6
7
1
Kelap mg fever
Deaths
Scarlet fever
Deathst
-
—
—
—
—
1 106
87
176
57
42
2416
142
221
81
176
Smallpox
Deaths
Typhoid fever
Deaths
Typhus fever
Deaths
Whoopinc-cough
-
—
—
—
—
—
~
_£
-
5
1
" 2
1
i
: —
—
1
1 1
-
-
-
—
—
—
—
—
-
3 735
13
; 360
; 2
1 604
1 77
' 3C
9361 39
63
a :
1
> 44
Deaths (0-1 year)
29S
> y.
1 a :
1 '
J u
) 33:
1 43
4”=
41
i 12
Deaths (excluding
stillbirths)
Annual death ratS
(per 1 000 per
sons living)
6 971
1 108!
; 791
15^
1 I8f
)
J I5-:
1 57L
i
1 863
701
14 I
25;
151
S 149
i
Live births
Annual rate per
1 000 persons
living
Stillbirths
Rate per 1 OOO
total births (in
6411
1 99!
! 805
16:
) 347
1
r 20(
; 6 565
) 1015
877
17 f
321
20:
5 204
2
)
t 21
J 21
2‘
[
17:
7 23
1 24
O'
Mca^le^ i** n )l notmaoie m olououu ou
"'TS-' frorJn^aslc. and ^aric. fever for England and Wal« London
^iTclnSVv pnraw'^^rm'VS? eS Wales London (adm.mstraUve
“""nfberordlsrlifrrcm pol.omyelim and Pol™|“"'-
Enstand and
II Includes
ii Primary
Jan 13 1951
MEDICALxNEWS
Bfunsu
MEDICAI. JOUKNAI.
101
Medical News
New Year Honours
In the New Year Honours a Knighthood was conferred on
Mr Percy Barter C B Chairman of the Board of Control
and on Mr Thomas Dalling M R C V S Chief Veterinary
Officer Ministry of Agriculture and Fisheries Mr Barter
has been Chairman of the Board of Control and Under Sec
relary Ministry of Health since 1945 having been previously
secretary of the Board from 1930 to 1939 and Principal
Assistant Secretary Ministry of Health from 1940 to 1945
Mr Dalling has undertaken important work on canine
distemper and on problems connected with immunization
against other animal diseases including tuberculosis
Amended National Formulary
The second amendment list dated 1950 has just been
issued The mam change is the introduction of dexampheta
mine (the official name for the proprietaries dexednne
and dexamed ) as Tabellae Dexamphetaminae Sulphatis
* Six tablets each containing 5 mg to be dispensed unless
otherwise directed
Profits from Streptomycin
Dr Albert Schatz of New York who was a student of
Dr Selman Waksman when streptomycin was discovered
recently brought a successful court action against Dr Waks
man for recognition as co discoverer and a share in the
royalties He will receive 3% of royalties accruing after
October 1 1950 and S150 000 dollars (about £43 500) for
relinquishing foreign rights in the antibiotic The net
royalties up to this date are estimated at some S2 360 000
(about £843 000) but Dr Waksman has received
only about S350 000 (£125 000) The remainder went to
the Rutgers Research and Endowment Foundation to which
Dr Waksman made over part of the rights It is not
directly connected with Rutgers University where the drug
was discovered Under the new settlement 7% of the net
royalties will be divided among 13 other graduate students
of Rutgers and cash bonuses will be paid to 12 assistants
The Foundation will still continue to receive 80% of the
streptomycin royalties and Dr Waksman will receive 10%
Originally Dr Waksman received 20% but when the
royalties began to mount up to big figures he asked the
Foundation to Cut his share by half
New Journal of Therapeutic^
The publication- of a new monthly journal Antibiotic
ami Chemotherapy is announced by the Washington Insti
tiite of Medicine Early contributions will include reviews
of the present status of antibiotic )herapy ACTH corti
sone the chemotherapy of tuberculosis and details of newer
antibiotics The journal is published from 1708 Massachu
setts Avenue Washington at a subscnption of SIO per
annum
In Brief '
Dr Edith Summerskill Minister of National Insurance is
visiting Egypt January J4-21 to study the development of
social services there ^
Wills
Dr Herbert Morley Fletcher formerly consulting physi
Clan St Bartholomew s Hospital London left £21 196, inclu ^
ding £100 to the Royal Medical Benevolent Fund Dr
Arthur StanbUry Cobbledick formerly of Trevone near
Padstow Cornwall left £11 738 including £100 to the Royal
Eye Hospital St George s Circus London S E Dr Doug
las Craig of Cornngham Essex left £27 000 Dr Robert
Percy McDonnell late chief medical adviser Department of
Local Government and Public Health Ireland left £11 838
He left £50 for Masses and £25 each to the Dubhn branches
of the N S P C C and S P &A
COMING EVENTS
Royal Institute of Public Health and Hygiene
Whole time and part time courses for the Certificate and
Diploma m Public Health and for the Diploma in Industrial
Health begin on various dates on and after January 26 Full
details may be obtained from the secretary 28 Portland
Place London W 1
Radiology Course '
The Faculty of Radiologists will hold a postgraduate
week end course on February 17 and 18 Lecture demon
stralions will be given on (I) diagnostic radiology and
(2) radiotherapy Full particulars may be obtained from
the honorary secretary Faculty of Radiologists 45 Lincoln s
Inn Fields London W C 2
>
Social and Preventive Paediatncs
A course of 10 lectures for postgraduates on social and
preventive paediatrics began at the Hospital for Sick
Children Great Ormond Street London W C on
January 8 when Sir James Spence spoke on The
Influence of Environment on Disease in Childhood
The remaining lectures will be delivered weekly on
Mondays at 5 p m until March 12 and ^details will be
published in the Societies and Lectures column of the
Journal The fee for the course is £3 3s (single lectures
7s 6d) and applications for tickets of admission accom
panied by a remittance should be sent to the secretary of
the Institute of Child Health at the hospital
' \
Psychopathology of Cerebral Diseases
Professor Manfred Bleuler of the University of Zurich
will deliver a lecture on The Psychopathology of Cerebral
Diseases at the Institute of Neurology National Hospital
Queen Square London WC on Tuesday February J 3
at 5 p m '
Polish Doctors in Great Bntam
An Assembly of Polish Doctors in Great Britain will
take place at B M A House Tavistock Square London
WC on Friday and Saturday January 39 and 20 On
January 19 the proceedings which begin at 11 am include
an address by Sir Alexander Fleming F R S on The
Search for Antibiotics and in the afternoon a paper by
Dr L Surzynski on Social and Professional Problems
Facing Emigr6 Polish Doctors Full particulars may be
obtained from the chairman of the Polish Medical
Association 14 Collmgham Gardens London SW5
SOCIETIES AND LECTURES
Monday
Durham University — At Royal Victoria Infirmary Newcastle
upon Tyne January 15 5 15 pm Experiments in Learning
Rutherford Morison Lecture by Professor J Z Young F R S
Hunterian Society — At the Mansion House London EC
January 15 8 30 pm The Atienographic Approach to the
Study of Arteritis by Professor F Orban (Li^ge)
©Institute of Child Health Hospital for Sick Children Great
Ormond Street London WC — January 15 5 pm The
Economics of Child Health by Dr J D Kershaw
Institute of Urology— At St Pauls Hospital Endell Street
London W C January 15 10 a m Calculous Disease of
Bladder and Urethra by Mr F J F Barrington llJOnm
Marion 5 Disease and Dixerticuhim of Bladder by Mr H ^
Vernon 2pm Congeniial Defects of Bladder and Urethra
by Mr J E Semple 3 30 p m demonstration Endoscopic
Instruments b> Mr A R C Higham 5pm Administration
of Sulphonamides and Antibiotics by Dr A H Harkn^
Roval Eye Hospital St Georges Circus Southwark London
SE — ^January 15 4 pm, Optics (Rexistoii) by Mr H N
Reed
ORoval Eye Hospital St George s Circus Southwark London
SE — January 15 530 pm Anatomy of the Eye and Orbit
by Professor T Nicol
Scientific Film Association Medical Comviittee — At Royal
Society of Medicine 1 Wimpole Street London W January
•55pm Films on Child Health will be shown and discussed
102 Jan 13. 1951
MEDICAL NEWS
Bwnsn
MZDtcJa. JovKNKt.
Tuesday
Mcdical Federation —At London School
w Medicine Keppel Street London,
' m *®i 5 30 p m Observations on the Circulation
in the Human Limbs by Professhr H Barcrott
Society Burlington House,
Piccadilly London W January 16 5 30 pm Congenital
Malformations by Dr C O Carter , *
•INSTITUTF or DcrMiTOLOGY Lisle Street Leicester Square
London WC— ^nnuary 16 5 p m Zdonoses (ParastUc
Infemoits) by Dr MS Thomson
Institute of Urology —(D Ai St Paul s Hospital EndclJ Street
London WC January 16 lOam Jniunes Benii^n Growths
Bodies tn the Bladder by Mr Harland Rees.
1 1 30 T m New Growths of the Bladder (li by Mr J G
^ndrey 2 pm New Growths of the Bladder f2l by
J ^ St Peter s Hospital Hennetia Sirccl
London wC 3 30 pm w-ird round by Mr Harland Rees
5 pm H Ufology of Bladder Growths by Dr C E Dukes
R(^al Evp Hospital Si Georges Circus Southwark London
SL-~JnnuTry 16 5 pm Sursery of the (ns by Mr T M
Tyrrell
Society for the Study of Addictiov— At Medical Society of
London 11 Clnndos Street Cavendish Square London W,
January 16 4 pm Chnicol Experiences tn the Treatment of ^
Alcoholism by Dr J A Hobson A discussion svill follow
England Linc^n s Inn Fields London WC, 215 nm
sjnnposmm The Reticuloses speakers Drs if M Levitt
Geoffrey Boden, (3) At Dorchester Hotel
London W 7 30 p m dinner '
British Institute of Radiology 32 Welbeck Street, London
W January_19 5 pm meeting of medical members
Wednesday
Harvehn Society OF London 11 Chandos Street London W —
January 17, 7 45 pm annual general meeting 8 45 pm
^ The Continuing Problem of Phthisis presidential address by
Dr R R Tnil
•Institute or Dermatoloov Lisle Street Leicester Square
Londop WC — January 17 5 pm, * Medical Mycology
lecture demonstration by Dr R W Riddell
Institute or Urology —At St Pauls Hospital Endell Street,
London WC January 17 1130 am A Survey of the
Methods of Treatment in Benign Prosfatic Enlargement by
Mr A C Morson 2 pm Hydronephrosis by Mr H P
Winsbury White 3 30 p m ' X rays by Mr H 1C Vernon
5 pm Museum Demonstration by Mr D I Williams
Royal Eye Hoseital St George s Circus Southwark London
SE — January 17 5 30 pm, Retinoblastoma by Mr R P
Crick
RoyVl Micboscopical Society Tavistock House South Tavistock
Square London W C — January 17 5 30 p m annual general
meeting 6pm The Virus and the Cell presidential address
by Dr G M Findlay
Thursday
British Institute of Radiology 32 Welbeck Street London,
W — January 18 8 15 pm joint meeting with Radio
logical Section Royal Society of Medicine and Faculty of
Radiologists Symposium The Reticuloses speakers
Drs W St C Symmers R Bodley Scott, and F Campbell
Golding I
British Postgraduate Medical Federation — At London School
of Hygiene and Tropical Medicine Keppel Street London
WC January 18 5 30 pm ' Cerebral Responses to Peripheral
Stimiih m Man by Dr G D Dawson
Edinburgh Clinical Club — At B M A Rooms 7 Drumsheugh
Gardens Edinburgh January 18 8pm Sinusitis and Nasal
Catarrh by Dr J F Birrell
Institute of Uhoiogy — ^Al St Pauls Hospital Endell Street
London W C January 18 10 am Retropubic Operations
on the Prostate by Mr A W Badenoch 1 1 30 a m Endo
scopic Operations on the Prostate by Mr A W Badenoch
2 pm Transiesical Operations on the Prostate by
Mr A R C Higham 3 30 p m ward round by Mr D I
Williams 5pm Radiotherapy and Radium by Dr S B
Osborn ^ ,
Liverpool Medical Institution 114 Mount Pleasant Liverpool
— January 18 8 pm Inguinal Hernia by Mr John A
RoyaL Eye Hospital St Georges Circus Southwark London *
SE — January 18 5 pm Ocular Palsy by Dr S Nevm
Royal Socifty of Tropical Medicine ano Hyoienp — At 26
Portland Place London W Januaiy 18 7 30 pm Foreami
(ponds Rente Ehsaheth pour I Assistance Medicate aitx
Indigenes) in the Belgian Congo by Professor- Ren6 Mouchet
St Gforge s Hospital Medical School Hvde Park Comer
London SW— January IS 4 30 pm lecture-demonstration
UNTORsm °^roLLErE (Phvsiolooy TheatbeI Gower Street *
London WC— January 18 5 15 pm Phuicocftem/col
Properf/a ond Pharmacological Acinity of Drugs by Mr r
Bergel, Ph D D Sc
Friday
British Institute of Kxdioiogy —January 19 lomt meeting
with R^dlo1oGlc^l Section Royal Soacty of Medicine and
Faculty of R'idiofo'’jsts continued ft) At Rovai Soaety of
Medicine ! Wimoole Street London W 10 30 am sym
Tjosium The Reficidoses speaker? Dr Bnan Russell
Profes<?or R McV^^irter Drs D G Galfon J D N Nabarro
and John Boland (2) At Royal College of Surgeons of
* wr^''i‘-°“^ 3 -At St Pauls Hospital Endell Street
London W C January 19 10 a m Malignant Disease of the
uTrr ,L I F"B“ssQn 1130 am Stricture of
I Semple 2pm, Infertihly of tlie
Male by Mr A R C Higham 3 30 p m Museum Demon
stranon by Mr J E Semple
London Association or the Medical Women s’ Federation —
At RoyabFree Hospital School of Medicine 8 Hunler Sircet
Brunswick Square London WC January 19 8 30 pm
iReeenl Deielopmems In Cardiac Surgery at Guys Hospital
by Mr Lawrence Whytehead
St Georges Circus Southwark London
S E —January 19 5 30 p m Phy'siology of the Eye
Royal Medical Society 7 Melbourne Place Edinburgh —
January 19 8 p m The Curious Effects of Carbon Monoxide
Poisoning address by Dr J K Slater
Saturday ,
Nutrition Society — At London School of Hvgiene and Tropical
Medicine Keppel Street Gower Street London W C January
20 ip30 am Tbe Comporame Merits of Animal and
Vegetable Foods in Ninnlion Discussion' speakers
Dr Tnsiram (St Andrews) Dr Carpenter (Rosvett Institute)
Dr Blaster fHannoh Dairy Research Institute) Dr Yates
(Rothamsted Institute) Dr Lucy Wills (Royal Free Hosniial)
Dr Harnette Chick (Cambridge) and Dr Deane (Cambridge)
Southeast Metropomtan Regionae Tuberculosis Society —
At Chest Clinic Health Department Town Hall WaKvorlb
Road London SE January 20 10 30 for 11 am general
meeting Clinical programme as follows Tuberculous Can
ditions of the Skin by Dr W G Tillman Oral Conditions
in Pulmonary Tuberculosis by Dr G E Kinp Turner discus
,sion ‘ Domiciliary Treoimenl of Pulmonary Ttiherndops bv
Dr E K Pnlchard At Bnmswick Tavern Old Kent Road
London, S E , I 30 p m luncheon
BIRTHS, MARRIAGES, AND DEATHS ^
BIRTHS
Bttlrtrode ~On January 5 1951 Hartwell Hou^c Harifleld Sussex lu
Jacqueline (formerly Kent) wife of Dr J C BuUtrode a son
Bablblt — On December 23 1950 to Stella Murray MB BS DCH
■ffUe of Dr H S Hablbls a son l
Boxbes— Oo January I 1951 at Torbay Hospital Torquay to Joy
(formerly Laxton) wife of Dr D R Hughes a second son—Richard
John
Mttrpti> — On D'*rpmh ’O 19^0 Tnei wife of Dr E f Murphy
Norihowram Hall Halifax a daujrhter
Sevrs — On December 31 1950 ai Hammersmith Hospital to Dr Janet
Var^ (formcrlv Conn) wife of Dr H T N Scars a daughter
I Tbpr^nit — Oi January 3 T9S1 in Trinidad to Gay wife of Dr John V
Thiif^ion a sifier for Graham — Sheila
Wefts — On January I 1951 ai Cardiff to Barbara (formerly Sharrait)
wife of Albert L Wells MB DCP Uandoueb House PenarJb
Glhia a son
MARRIAGES
CoodsoB— Tnyfor — On December 26 19^0 at the Parish Church Tacoma
Washington USA Michael Piers Ooodson M A MB B Chir m
Leonora Taylor S R N both of London ,
DEATHS
Bertram —On December 16 1950 at his home Masons llton Tlminstcr
Somerset Drummond Rcwcastle Forbes Bertram OBE MB BS
D M R Surgeon Commander R N retired aged 47
Caibcjirt — On January 4 J9^1 at South Court Nursing Home Broad tairs
George Clark Caihcari M D of 11 Upper Wimpole Street London
VY aged 90
Cooper— On December 21 19*:0 William Francis Cooper MB BCh
late ol Hericnnibe Coombe Warren Kingston Surrey
Coorts— On December 19 19‘iO at 47 Rouge Bouillon St Heller Jersey
C I Duncan Couits M D F R C O G Lieutenant Colonel i M S
rrilrcd agro 68 . .
Fraw— On December 22 1950 at Pitlochry Donald Alexander Fraser
MBCbBDPH tn.,.
Prater— On January 2 1951 at 16 Albvn Place Aberdeen Thomas
FraerCBE D90 TD LLD MB <jhB DPH aged 78
Freoch — On January 1 19^ at Guy s Hospital London S E Herbert
Stanley French CVO CBE MD FRCP of Cudworth Manor
Newdigate Surrey aged 76 ^
Gtrdirstnne —On December 30 1930 Gathorne Robert Girdlcstonc D M
FRCS of Fnlford Heath Berks aged 69
Colls —On December 2S 1930 at Du Can Court London S W Robert
C>iIIuro Gully M D formerly of St George a Road Souinwarx
HaiTfs'^-^n^Deccniher 26 19^0 at 105 Whipps Cross Roa4
London E Samo on O-oree Victor Hams MD t)PH aged 85
Heath— On December 23 1950 at Barmouth Merioneth
Heard M R C S IP CP used 63
Llnl a —Or December 22 19*^0 at a nursing home Glasgow
Feirwlck Lin on MB Ch B Lunan Lodge , Renfrew
Maemmso —On December 24 !9<0 Hugh Agnew Macmillan M C M u
of The Carnens Meihii Fife ^ .
Martin —On December 2? 1950 at Elford Douglas Avenue _
Qaude Buisl Martin t M O MB CM Colonel
aged 81 '
John RlPPloer
Robert
Exmoutb
A MS fcdred
Jan 13 1951
ANY QUE^ONS 7
British
Medical Journal
103
Any Questions?
Correspondents should their names and addresses (not
for publication) and include all rele\ant details in their
questions u Inch should be ty ped We publish here a selec
tion of those questions and ansners which seem to be of
general interest
Treatment of Psychoses ith A C T H or Cortisone
Q — treatment with adrenocorticotropic hormone
(A CT H ) or cortisone likely to help a patient suffering
from a manic depressne psychosis^
A — ^Treatment of manic depressive psychosis by ACTH
or cortisone is still in the experimental stage It has been
observed that in mennily healthy people injection of large
amounts of these substances produces undesirable mental
changes It would therefore be risky to treat those already
mentally ill by this means unless full prelautions were
taken and it would be unjustifiable except as part of a
controlled experiment A number of psychotic patients
have however with due regard for these points been
treated m the United States by investigators primarily con
earned with the response of the adrenal cortex to stress
in certain mental disorders M D Altschule' and his
colleagues in Boston have found that patients with schizo
phrema and severe depression show greater than normal
changes m carbohydrate metaboUsm after the injection of
ACTH and their eosinophil count uric acid and 17
ketosteroid excretion are not diminished as they would be
in non psychotic persons given ACTH These investiga
tors record unsatisfactory results from the clinical stand
point in a depressed elderly woman the ACTH caused
hallucinations to develop and she was still extremely
agitated and depressed after the administration of 570 mg
of ACTH spread over 17 days a younger woman also
depressed became rather worse after 900 mg of ACTH
spread over 10 days others became more tense and rest
less In Montreal another group of workers* headed by
R A Clcghorn has administered ACTH to manic as
well as to depressed patients chiefly to study abnormalities
of adrenal cortical function m manic depressive disorders
In the depressed patients a slight iniiial improvement m
their mental state was followed by some increased tension
any improvement disappeared quickly when the injection of
ACTH was stopped A manic patient treated by Clcghorn
with cortisone for two weeks improved so long as the
cortisone was being given but it could not safely be con
eluded that the cortisone was directly responsible for this
In an investigation in New York City J J Smith* likewise
found that ACTH m large quantities had not effected
any clinical improvement in a few patients with agitated
depression and mama whom he treated
Refirences
^ A r-h Neu ot PirchUl Ch^>‘n^n 1950 64 641
* Canad m d Ass J 19S0 63 325 and 329
* Quart J Stud At ohol 1950 11 190
Persistent Urethral Discharge
Q — A patient of mine has had a sero purulent urethral
discharge for the last fj\e months Repeated bacterio-
logical examination confirms the absence of gonococci
but there is a mixed flora of non haemolytic streptococa
diphtheroids and small Gram negati\e bacilli Penicillin
and (he sulphonanudes ha\e failed to clear up the dis-
charge What further inxestigations and treatment would
you suggest and is there any likelihood of a subsequent
urethral stricture de\ eloping ^
\ — Before answering the query it should be emphasized
that thorough cleansing of the meatus with spint should
precede the taking of specimens for microscopical examma
tion Most non gonococcal urethral discharges are abacterial
but inadequate cleansing often leads to the mistaken diag
nosis that one or more of the normal saprophitic flora is
responsible for the infection A bacterial (non gonococcal)
urcthntis is extremely rare such cases as there are being
either due to mechanical causes (usually the insertion of
foreign bodies) or secondary to infections of the upper
urinary tract
The patient in question is in all probabihl> suffering
from an abacterial urethritis In these cases there is often
a history of intercourse during or near a period A possible
explanation of this is that at such times the cervical canal
opens up and becomes more vascular and thus allows much
more epithelium (containing the infective agent) to be
desquamated into the vagina Such infections are always
resistant to penicillin and the sulphonamides but aureo
mycin 05 g eight hourly by mouth for three da>s effects
a cure in at least 80% of cases Urethral stricture is a
common sequel when the disease is of long standing Stne
ture which is never serious can be diagnosed only by
urethroscopy (it is called urethroscopic stricture ) as there
15 no diminution in the calibre of the urethra On the other
hand if the mfection is bacterial hard stnetures as in
goQOrrboea may occur If further laborator> investiga
tions show that the condition is bactenal in origin a thorough
investigation of the upper urinary tract should be carried out
by a urologist
Haeroobtic Disease of the Newborn
Q — I would be glad of your adxice on the following
cose the mother is Group 0 Rh negatjye the father is
Group O homoz\pou5 Rh positne (type RhRh-^^Def
cDE) The only child IS Group O Rh positwe (type Rhirh—
cDE(cde) The second pregnancy proceeded normally anti
bodies developing in low litre at the 26th week The tiirc
gradually rose until the 35th week when they were If 512
m serum albumin No blocking antibodies e\er de\ eloped
At the 36th week the litre doubled bur induction of labour
was not carried out A few days later the child died in
utero The patient has been told that in all future preg
nancies the child will be affected and may die in utero or
if born alive will reauire exsangmnation transfusion Jf this
IS correct can anything' be done to prexent an antibody
response ^ Is hapten of any use ^ If treatment w ill not
prevent foetal damage should the patient be allowed to
become pregnant again ^
A — The question does not give as full details as
would be desirable If the ^parents concerned have
the commonest genotypes of the phenotypes slated — i e
that the mother is rhrh (ede/ede) and the father Rh Rh,
CDe/cDE) and that the antibody is anti D — then any future
pregnancy must be expected to yield a child suffering from
haemolytic disease
At the present time no method is known by which the
maternal antibody response can be prevented or the foetus
protected from the antibodies The extracts which it was
thought might have contained Rh hapten have not given
satisfactory results in clinical tnals and their action in
vitro IS thought to be non specific Such other substances
as have been tried have been ineffective with the possible
exception of methionine'-which was thought to be of value
by N W Philpott M Hendelman and T Primrose (Amer
/ Obsiet Gynec 1949 57 125) TTieir results have not
as yet been confirmed by other workers
The procedures which should be considered in a future
pregnancy are induction of labour and replacement trans-
fusion The table below shows the results of such treat
ment m 46 Rh positive pregnancies in which the mothers
had borne at least one previous child affected with haemo
lytic disease The plan of treatment was to induce labour
surgically at 36 weeks or as soon aftenvards as the foetus
was considered large enough a minimum weight of 5 to
5i pounds (2 26 to 2 48 kg ) as estimated by the obstelriaan
being required before induction w’as allowed All
ANY QUESTIONS 7
f
104 Jan 13, 1951
the mildest cases of haemolytic disease received a replace
mem transfusion of one pint of compatible blood within
a few hours of birth The indications for replacement
transfusion cannot as yet be laid down clearly but as a
general rule any child with a positive direct Coombs, test
and a cord haemoglobin level of under 151 g per 100 ml
should receive -one Although the serifes quoted is small,
it shows th It the prognosis for such a pregnancy is not
hopeless .
Stillborn
Neonatal
Death
Survived
Re ' o'- 1 , -
s* s !
Results of latest pregnancies of 27
mothers whose previous ofTccted infant
S
5
9*
was born alive
5
1
5
1
17
• Includes one case of kernicterui
The problem of allowing further pregnancies is one for
the jiarents to consider after they have been informed of
the probable risk' If, as is generally the case they decide
that a further pregnancy is undesirable then advice on
contraception should be given In the uncomplicated case
there are no grounds for advising either sterilization or
termination of pregnancy '
1
Dupuytren’s Contracture
N
U — How ihoiiht Dtipiiylrcn s contractmc be treated^ Is
iiiamin C oj value in this condiitoti^
A — ^Thc treatment of Dppuyiren s contracture is still
entirely an operative one The classical methods of sub
cutaneous fasciotomy and excision of the affected fascia
are still ^he two basic procedures fn the past it was
tustomarjT to use fasciotomy for the mild cases and exci
Sion of the fascia for the set ere cases The present atti
■ tude ts the reverse The mild or moderate cases are those
best suited to excision of the fascii, and in these 'an
excellent result can be expected In the severely con
traded cases fasciotomy is performed to explore the possi
bility of treatment by excision ^In most of them excision is
of no value as the joints of the finger are commonly still
or subluxated If a tentative fasciotomy shows this to be
the case no operative treatment other than amputation is to
be advised In the operative excision of the fascia it is
" imperative to remove all skin which is involved in the
1 Dupuytren process Closure of the skin by means of a
Z plasty Is a very valuable adjunct to the operation
It IS almost certain that vitamin E is valueless in this
condition Various writers have reported success with hqavy
doses of this vitamin (see British Medical Journal 1949, 2
1399) while others (for example A R King J Bone Jl
Siirg 1949 3J B 443) have reported equal failure Many
of the improvements were of subjective type the patients
saying that the hands felt softer or the fingers felt straighter
and that the aching pain bad gone Some observers have
reported objective improvement in the extension of the
fingers others have reported failure of improvement in
objective signs One writer comments that m 12 cases out
of 13 no value was seen with treatment at full dosage for
six to eight weeks at a cost of approximately £5 per week
Adiposis Dolorosa
Q —Js anything known of the aetiology and treatment of
adiposis dolorosa ^
\ — There is no pathological basis for the differentiation
of adiposis dolorosa from other forms of adiposity, although
clinically the name is used if the adipose deposits tend to be
- painful and the patient depressed or melancholic
The question therefore involves discussion of the whole
complex problem of adiposity This also applies to treat
ment which has been dealt with manv times in these
, Bmtrh
\ Medical Journ al
columns and broadly speaking involves three lines of
approach dieting and the use of appetite depressors and
diuretics Thyroid is of limited .value, and there is no
hormone known which specifically catabolizes fat
I Urticaria m 8 week old Twin
Q— f have under my care a bab\ of 8 weeks one of
tdenttcal twins He iiaj quite well until two weeks ago
when an urticarial rash dev eloped and he began voiiiitiiig
he was also constipated Examination showed that the
colon was loaded with hard faeces and treatment of the
constipation cured the vomiting However the urticaria
has ^continued the hands have been grossly swollen and
huge weals have appeared on the face and trunk On
the assumption that the urticaria might be due to woollen
clothes or to the detergent these were washed in the child
lias given cotton underclothes washed in soapflakes onlv
In spite of this the condition has persisted and now one
leg IS grossly swollen The other twin although having
the same food (national dried milk) and living in the same
environment is quite well and is non two pounds heaiiei
than his brother Can you till me (I) What is the youngest
age at which urticaria occurs (2) Does the fact that one
twin has reacted differently to the same condition prou
that the twins are not identical > (3) Is it safe to give anti
histamine drugs to children of 8 weeks and if so* ii /ml is
the dosage
A — ^The answers to the three questions are (1) Urticaria
may appear at any age and has been reported in the new '
born (2) A different reaction to the same condition m
twins does not prove that they are not identical because
other factors may not be the same but in general one vtioiild
expect identical twins to react in the same way (3) The
antihistamine drugs at present dh the market can safely be
given to infants who seem to tolerate them better than most
adults The dose vanes according to the drug used but
those for which a single adult dose is 25 mg can be given
in 10 mg doses up tq a total daily maximum equal to
about 3 mg per pound (0 45 kg) of body weight
It IS rather unusual for an allergic reaction to cause such
persistent swelling of the limbs Is it possible that some
other condition iSj present as well as an allergic reaction
with urticaria Vomiting and urticaria in a bottle fed
baby suggest a milk allergy although colic and loose fatty
or undigested stools would be expected rather than constipa
tion It IS important to find the allergen before exhibiting
antihistamine drugs, and it would be best to place the child
on a boiled water or glucose water diet for a couple of
days to see if the symptoms disappear It they do then
It would be wise to feed the child upon a soya bean prepara
tion before attempting to desensitize him to cow s milk
The delay in the appearance of symptoms docs not rule
out the possibility of sensitivity to cow s milk
NOTES AND COMIWENTS
Correction — In the obituary notice of Sir Leonard Parsons
which was published in the Journal of December 30 1950 it vns
wrongly stated that Sir Gilbert Barling was co editor with Sir
Leonard Parsons of Disease in Infancy and CInIdIwod It was
Mr Seymour Barling who was co editor of this textbook
.11 communications ‘with rcaard to editorial business should be addre^cd
lo The editor Bmtish Medical Jouenal B M A House Tavistoce
Sqoake London W C I Telephone EUSTON 211 1 ,,, T‘i‘'rTTc» s
Aitiotogy VVesIcenI London ORIGINAL ARTICl^S AND LETTE
lorwardcd lor publication arc undcrslood to be ottered to the ariasn
Mrdical Journal alone unless the conltary be staled. -
uUtors dcslrinc REPRINTS should communicate with the Piibb bine
Manaeer B M A House Tavistocb Square W C I on receipt of proms
Authors oerstais should Indjcaie on MSS »f reprints arc required
proofs are not sent abroad . _ .
DVERTfSEMENTS thoJld be addressed lo ^ id
B M A Hou r Tavistock Square London W C I (hours 9 J
5 pro) Telephone EUSTON s2111 Telegrams Drltmedads
[msSS SUBSCRIPTIONS should be sent to the SECRETARY of ^
Aasociahon Telephone EUSTON 2111 Telecraa<s Mtnse
tVestcent Lonaon . .
A JsroTTi.cH Office 7 Drumsheugh Gardens Edinburgh
LO>DON SATURDAY JANUARY 20 1951
HORMONES OF THE SYMPATHETIC NERVOUS SYSTEM AND THE
ADRENAL MEDULLA"
U S >on EULER, MD
(From the Department of Physiolog\ KaroUnska Institute Stockholm)
The substances which determine the action of adrenergic
nerses and of the internal secretion of the adrenal
medulla are of equal interest from the physiological and
the pharmacological point of Mew In the elucidation
of this problem as a whole pharmacological methods of
analysis have largely been used, and with considerable
success, demonstratmg the value of pharmacological tools
in solving physiological and even chemical problems
The concept of a neurohumoral transmission of nerve
impulses takes us back to Elliott (1905) in England who,
on account of the similarity of action of sympathetic
nerve stimulation and adrenaline propounded the hvpo
thesis that such nerve impulses became effective by
liberating adrenaline at the nerve endings To prove
this was not so easv however and in spite of several
attempts it was not until 1921 that Loewi in Graz and
Cannon and Uridil in Boston, demonstrated the release
of an active adrenaline like substance as a result of
sympathetic nerve stimulation It v/as as in Elliotts
day considered almost self evident that this substance
was adrenaline At a time, however, when everybody
else seemed to be satisfied with the identitj of the actions
of adrenaline and sympathetic nerve stimulation, Barger
and Dale (1910-11) in their classical study on sympafho
mimetic amines noted significant differences in this
respect, and also pointed out that better agreement was
found with the non methylated ethanol amino base
noradrenaline This most important recognition was
however overlooked for a long time and as late as
1939 Cannon and his co workers believed that adrenalme
was the mediator of the adrenergic nerves
CH(OH)CH, NH(CH,) CH(pH)CH, NH,
Adrenaline lYoradrem me
Cmeth>lanunoethanolcatechol)
On the other hand Cannon and Rosenblueth (1933)
discovered that stmiulation of sympathetic nerves pro
duced actions which necessitated the assumption of two
different active substances which were called sympathm I
and E owing to their inhibitory and exeitatory actions
These substances were believed to be formed by the
•Lecture given b> invitation of the University of London al
St Mary s Hospital on October 17 1950
interaction of the mediator and constituents of the
reacting cells With increasing knowledge of the action
of sympathomimetic amines the idea gradually dev eloped
however, that noradrenaline might be responsible for
the excitatory reactions and adrenaline for the inhibi
tory ones (Bacq 1934 Melville 1937 Stehle and
Ellsworth, 1937 , Greer et al 1938) although these con
cepts did not seem to become generally accepted
A closer analysis of the sympathomimetic action of
suitably purified extracts of organs and nerves, under
taken in our laboratory in 1944-6 revealed however
that the responsible substance or substances differed dis
tinctly from adrenalme in several respects (Euler 1946)
The suspicion that the activity might be due to nor
adrenaline proved fruitful, and it could be shown by
various biological and chemical tests that there was a
close agreement between the actions of the extracts and
noradrenaline Holtz et al (1947) demonstrated inde
pendently the probable presence of noradrenaline in
urine and m suprarenal extracts In the same year
Gaddum and Goodwm (1947) showed that the substance
liberated on electrical stimulation of sympathetic nerves
could be noradrenalme and shortly aftenvards Folkovv
and Uvnas (1948) obtained evidence for the liberation
of noradrenaline in vascular reflexes in the cat Tu'lar
(1948) succeeded in resolving racemic synthetic nor
adrenalme, or arterenol into its optical isomers and
L-noradrenalme became available By biological and
chemical methods the active sympathomimetic principle
m nerves and L noradrenaline were shown to have a
close agreement, strongly supporting their identity
The pharmacology of noradrenaline then naturally
aroused great interest, and some of its more important
actions are mentioned below, especially in comparison
with Its more time-honoured and well known homologue
adrenaline
Action on Smooth muscle Organs
As already noted by Barger and Dale, noradrenalme
has a rather weaker i^ibitory effect than adrenahne on
smooth muscle organs, such as the uterus and intestine
of the cat Large variations m the effects occur, how ever
on oifferent organs Thus the relative effects on the
intestmc do not differ much adrenaline being only about
twice as active at most On the rats uterus on the
other hand the inhibitory action of adrenaline may
106 Jan 20 1951
HORMONES AND THE ADRENAL MEDULLA
BumsH
Medicai. journal
as much as 300 times stronger than that of noradrenaline
Other organs, such as the ins, the cat s uterus, bronchial
muscles, and the fowl s rectal caecum, are intermediate
in their responses
An interesting feature in the response to the two
catechol derivatives has been observed by Burn and
Hutcheon (1949) after denervation of the nictitating
membrane in the cat the sensitivity is increased only
moderately for adrenaline but up to nine times for nor-
adrenaline I shall not enter into a discussion of this
remarkable change in action It has been suggested that
It IS due to the possible removal by denervation of
normally occurring inactivating enzymes
In contracting the uterus of the pregnant cat nor
adrenahne is more active than adrenaline
Action on Heart and Circulation
Some of the most conspicuous actions of noradrenaline
and adrenaline are their circulatory effects Whereas
adrenaline produces the vvell known rise in systolic blood
pressure, it has only little action on the diastolic pres-
sure , in fact, this may be lowered leaving the mean
pressure almost unchanged The minute volume of the
heart is increased Again,'-thc unaltered level of mean
blood pressure in conjunction with the increased minute
volume signifies that the sum total of the vascular effects
of adrenaline is a vasodilatation This is in sharp con
trast to the effect of noradrenaline, which produces an
almost parallel rise in systolic and diastolic blood pres
sure and also bradycardia (Barcroft and Konzett, 1949 ,
Svvan^ 1949 Kappert et al , 1950) Noradrenaline in
moderate doses produces no change in the minute-volume
of the heart, and since the mean blood pressure rises
one must infer a general vasoconstriction (Goldenberg
el al , 1948)
-The only vascular areas which so far have been found
to respond to noradrenaline with vasodilatation are the
coronary arteries and possibly the intestinal vessels when
small doses are employed Noradrenaline also has a
smaller constrictor action on the renal blood flow than
adrenaline (Burn and Hutcheon, 1949)
It isinot surprising that noradrenaline has been linked
with hypertension, since many features in hypertension
seem to be consistent with an action of noradrenaline
Goldenberg et a! (1948) have measured the blood
pressure-raismg effect of a constant infusion of nor
adrenaline in various doses on normotensive and
hypertensive patients and observed a rather stronger
response in hypertensives The reason for this differ-
^ence, which has also been noted by Moeller and
Koppermann (1950), has not yet been elucidated, how-
ever If the reason were a relative insufficiency in the
inactivation of noradrenaline one might expect to find
an increased output of the catechol amines in the urine
but this does not seem to be the case, in essential
hypertension at least
Action on the Metabolism
The calongenic action of adrenaline has been known
for a long time, and has been demonstrated not only
on the total oxygen consumption in animals and man
but also on isolated organs and minced tissues In man
a dose of 0 01 mg per kg given subcutaneously will
increase the oxygen consumption by some 25% Nor
adrenaline is much less active in this respect as borne
out by a series of recent investigations in animals and
man Goldenberg and his associates found hardly anv
action at all on infusion of 0 15 jtg of noradrenaline
per kg per minute in man, m contrast to adrenaline,
which in the same dose increased oxygen consumption
by some 25% Bigger doses of noradrenaline had a
moderately stimulating effect on the metabolism
The glycaemic effect of noradrenaline is likewise much
less marked than that of adrenaline, and the relative acti
vity has been estimated at about 1 10 Also, nor
adrenaline is less active in the formation of lactic acid
The recent increase in interest in the pituitarj-adrena!
system, m connexion with the use of cortical hormones
and A C T H in the treatment of chronic arthritis and
other conditions, has directed attention to the mechanism
of the release of these hormones It has been shown
that adrenaline is effective in hberating cortical bor
mones and also that this effect is mediated by the hypo
physis The fall in blood eosinophils caused by adreno
cortical hormones has been used as a quantitative test
of the release of A C T H , and the effects of adrenaline
and noradrenaline m this respect have been compared
Humphreys and Raab (1950) found noradrenaline to be
only one sixth as active as adrenaline Also adrenaline
IS more active in decreasing the ascorbic acid content
of the suprarenals (Nasmyth, 1949)
Differences iii action between the two catechol deriva
tives have also been noticed vvith regard to the effect
on the central nervous system It is a common obser
vation that in man adrenaline produces a peculiar feel
ing of anxiety, discomfort, and irritation Noradrenaline
in doses which cause a much larger rise in blood pres^
sure, has no such effect, or a rather weak one
Toxicity
An interesting difference between adrenaline and nor
adrenaline from the pharmacological point of view has
been observed as regards toxicity Already in 1906
Biberfeld had noted that noradrenaline was considerably
less toxic than adrenaline for rabbits and rats This
has been confirmed by Tamter et al (1948) who found
that L-zioradrenaline was no less than eight tunes less
toxic on mice in single cages than L-adrenaline
Out of these differences in action one may draw
certain conclusions not only about the nature of the
physiologically active catechols but also about the indi
cations when these substances are to be used as thera
peutic agents Adrenaline has been used, sometimes
rather indiscriminately, in circulatory collapse, a use
which IS largely based on an erroneous conception ot
its mode of action Por the restoration of blood pres
sure noradrenaline is much better suited than adrenaline
and has already proved valuable in combating low hlo™
pressure in operational shock It may be administerw
with advantage as an infusion Noradrenaline would
also cause less disturbing side actions when used as a
vasoconstrictor togetherwithjocal analgesics The sails
factory actions of adrenaline in counteracting circula
tory collapse sometimes noted, may well be due to the
fact that the so called natural adrenaline ’ on the
market may contain up to 20% noradrenaline
Some Chemical Properties
Adrenaline and noradrenaline may be chemicallv
separated from each other either by pure chemical
methods, using the difference m solubility ot certain
salts, or by partition in different solvents Craigs
counter current distribution technique allows a goon
separation when phenol and 0 02/N HCl are use as
solvents
Jan 20 1951
HORMONES AND THE ADRENAL MEDULLA
BRimii
MEDICAI. JOUllNAl.
107
Also partition chromatographj on starch columns
and paper chromatography, may be used N butanol
hydrochloric acid or phenol-water mixtures have prored
useful
/Voradrenaline shows a greater resistance to oxidation
than adrenaline Thns a solution of noradrenaline at
pH 3 5-4 IS very slowly oxidized by iodine to the
coloured product lodonoradrenochrome whereas adren
aline is rapidly oxidized An interesting difference is
also found m the fluorescence in ultra violet light of
oxidation products of the two substances The fluor-
escent substance formed by noradrenaline (noradreno
lutin) emits a less intense light than does adrenolutin
Estimation
Noradrenaline may be assayed biologically or colon
metrically against a chemically pure standard Usually
the problem is complicated by the fact that noradrenaline
almost always occurs together with adrenaline which
necessitates a more complicated procedure However
the variations in the activity ratio of adrenaline and
noradrenaline on vanous test preparations make it pos
sible to estimate the two catechols in a mixture A
useful pair of test preparations is the cat s blood pres
sure where noradrenaline is some two to four times
more active than adrenaline and the fowls rectal
caecum or the rats uterus where adrenaline is much
more active than noradrenaline
The extract is evaluated m terms of either one of the
two catechols against a standard and the relative acti
vity of the two catechols determined in the two tests
By a simp’e formula (Euler, 1949), the amount of each
catechol can be computed This procedure of course
necessitates extracts which are essentiallj free from any
contaminating active substance Adsorption on alumina
gives satisfactory extracts If the amounts of catechol
derivatives are large enough as for instance in supra
renal extracts, the assay can be made colorimetrically,
which IS simpler In this case use is made of the dif
ferent oxidation velocities at pH 4 and pH 6 At pH 4
all of the adrenaline is oxidized to the coloured com
pound in one and a half minutes whereas only some
10% of the noradrenalme is oxidized At pH 6 all of
the adrenaline and /loradrenaline is oxidized to the
coloured compound in three minutes A simple calcula
tion gises the actual amounts of the two substances
(Euler and Hamberg 1949)
Distribution
Noradrenaline is widely distributed in the body and
has in fact been found in all nerves containing adrenergic
fibres and consequently m almost all organs and tissues
including the blood and also in aqueous humour urine
and glandular sccrebons Only the placenta and perhaps
the bone marrow seem to lack these ergones In the
placenta there are no nenes and in the bone marrow
one could imagine that there would be little need of
vasomotor nerves since there is no margin for expan
Sion or contraction The amounts found in tvpical
adrenergic nenes such as the splenic nencs are quite
large (1&-20 pg per g) In the spleen the content is
considerable (3-4 pg per g ) indicating that the pen
pheral parts of the nerves contain comparativelv large
amounts The content in the heart is also relatively
large In the central nervous system no more than
0 2 pg per g was found (rabbit) — that is something
like I % of the content of the splenic nerves The same
IS the case for histamine
The amount of adrenaline occurring together with
noradrenaline in adrenergic nerves and organs is usually
only a few per cent of the total catechol amines, show
ing that noradrenaline is the dominating adrenergic
neurohormone The Table shows the abso'ute catechol
amine content (in pg per g ) of some organs and nerves
and also the relative amount of adrenaline After stimu
lation the two substances apparently are released in
Organ
[ Cow
1 Sheep
Tefal
Catechol
per 8
Adrenaline
Total
Catechol
perg
/
Adrenaline
Spleen
1 1-2 6
4-1 1
1 6
5
26
3
Heart
0 2-0 4 :
20-26
09
20
Lung
1
008
25
Brain
0 02 1
13
Kidney
0 1
4
Striated mu&cle
OOl
0 03
5
Lymph gland
08
03
25
Submaxillary gland
Ofr-l I
15-37
Splenic nerves
7 6-9 6
11-3 5 1
5 1-8 3
1 2-7
Mesentenc nerves
3
1 1-1 3
- 2-«
3 5“
2
Vagus ncr es
1 0 1
0 5-1 5
4 5-7 5
Sympatheiic trunk
2 5-5 '
1 1-3 8
1 6-7 5
Sciatic trunk
1
1
0 18
7
about the same proportion as they occur in the nerve
(Peart, 1949) After denervation the content in the
nerve and the corresponding organs diminishes greatly
so as to leave even less than 0 5 % of the original amount
(Cannon and Lissak 1939 Goodall 1950b)
Occurrence in Blood and in Urine — Noradrenaline
seems to be normally present in small amounts in the
venous blood of man and animals In purified extracts
It has been demonstrated biologically in amounts of the
order of 1-2 pg of noradrenalme per 100 ml of blood
(Euler and Schmiterlow 1947) It is likely that some
adrenaline is also present in the blood The presence
of the catechol amines in the blood is also compatible
with the fact that they occur normally in urine as shown
originally by Holtz el al (1947) and confirmed by us
The larger part is present in a free form but apparently
some IS conjugated and may be liberated by acid hydro
lysis The amount m the urine of normal man is of
the order of 30 pg of L noradrenalme a day and some
10 pg of L adrenaline
Siiprarenals and Chromaffin cell T amours — ^The first
intimation of the presence of noradrenalme in the supra-
renals was made in 1947 by Holtz and his associates
Their findings were soon confirmed and extended, by
several groups m vanous countries It was isolated from
suprarenal extracts m 1949 (Bergstrom, Euler, and
Hamberg 1949) By using paper chromatography the
separation of noradrenalme and adrenaline was first
demonstrated by James (1948), and this method also
indicated that these two catechol derivatives were the
only ones to be found normally in most 'suprarenal '
extracts The relative amounts of adrenaline and nor
adrenaline varj greatly in different animals and also in
the same animal during different conditions In the
rabbit almost all of the catechol amines are adrenaline
but in the cat the noradrenalme may constitute more
than 50% of the total In chromaffin cell tumours the
noradrenalme content maj be very high as originally
shown by Holton (1949) and confirmed b> severaf other
authors In other cases however adrenaline and nor-
adrenaline mav occur m about equal amounts depend
mg on the site and nature of the tumour ^
108 Jan 20, 1951
HORMONES AND THE ADRENAL MEDULLA
British
Medical Journal
Fonnahon and Fate in the Body
The discovery of Holtz and associates that animal
organs contain an enzyme capable of decarboxylating
dihydroxyphenylalanine (D O P A ) into hydroxytyr-
amme (L-dopa decarboxylase) indicated a possible way
of formation of noradrenaline, as already pointed out
by Blaschko in 1942 Langemann (1950) found dopa
decarboxylase in considerable quantities in suprarenals
An important contribution has been made by Goodall
(1950a), who found certain amounts of hydroxytyramine
in normal sheep s hearts He also demonstrated DOPA
in sheep suprarenals after thyroidectomy Hydroxytyr-
amine seems to occur regularly in urine One may
therefore depict the formation of noradrenaline along
the following hnes
OH
P|OH _co.
CHjCHCOOH
kn,
DOPA
The process by which a hydroxy group is introduced
in the side chain is still unknown, although it has been
observed to occur in vitro
Noradrenahne is partly inactivated by means of an
amine oxidase and a catechol oxidase in the body, and
partly eliminated in the urine, where it appears chiefly in
free form
On certain occasions the amounts excreted are rather
higher than normally, as, for instance, in muscular work
(Euler and Hellner, 1951) and in cases of chromaffin-cell
tumours In the latter cases excretions amounting to
more than 1,000 /ng a day have been observed (Engel
and Euler, 1950), a circumstance which has been utilized
as a way of diagnosing such tumours In such cases the
urine may be assayed directly on the cat s blood pressure
Highly interesting are the findings of Blaschko and
Burn (1950) concerning the inactivation of a mixture
of noradrenaline and adrenaline by means of an amine
oxidase preparation from rabbit liver They found that,
as incubation proceeded, the relative amount of nor
adrenaline steadily fell from 50 to 10% and the per-
centage of adrenaline rose from 50 to 90% Indepen-
dently Udd^n m our laboratory found that noradrenaline
IS much more readily inactivated on mcubation with
splenic nerve tissue of cattle than is adrenahne
The form in which noradrenaline and adrenahne are
present in the nervous tissue is still unknown However
both catechol ammes form ether-soluble compounds with
lecithin In equilibrium with a water phase the amounts
taken up by the lecithin ether are greatly dependent
on the pH Thus at pH 7 some 25-30% of the catechol
amines may occur in the ether-lecithin phase, whereas
at pH 5 only some 5% is bound to the lecithin in ether
solution (Norlander, 1950)
One may imagine that the catechol ammes could be
bound to phosphatids m the nerve and liberated by a
shift in acidity
Significance of Noradrenaline in the Body — The sig
nificance of the occurrence of noradrenaline m the
organism has been questioned in some quarters where
It IS thought that noradrenaline is merely a precursor of
adrenahne and serves no independent function This is
however, m obvious opposition to the findings that the
CH,CH,NH, CH(OH)CH,NH,
Hydroxytyramine Noradrenaline
normal reflex vascular effects in reality are effectuated
chiefly by noradrenaline It appears that noradrenaline
IS the sympathetic neuro ergone for general service, the
adrenahne acting as an adjuvant for more special pur
poses, especially as regards metabolic actions
Alterations in Distribution of Noradrenaline and
Adrenaline — ^A disturbance in the v distribution of the
two catechol ammes is encountered in connexion with
various endocrine disturbances, such as after hypo
physectomy, in thyrotoxicosis, after thyroidectomy, and
in other conditions This applies to the suprarenal
medulla, and other organs as well In the rat’s spleen,
after hypophysectomy, the adrenaline percentage is con
siderably increased (Euler and Hokfelt, 1950), and after
thyroidectomy it is markedly decreased (Goodall, 1950b)
A large field is opening up here which may be of interest
for the interpretation of certain vegetative disorders in
connexion with hormonal imbalance
References
Baca Z M (1934) Ann Physiol Physicochim biol 10 467
Barcroft H , and Konzett H (1949) ] Physiol 110 194
BarEer, G and Dale H H (191(3-11) Ibid 41 19
Ber£strom S Euler U S v and Hamberg U (1949) Acta
chem scand 3 305
Biberfeld J (1905) Med Klin 2 1177
Blaschko H (1942) 1 Physiol 101 337 , .
and Bum J H (1950) Physiol Soc Meeting at Oxford
July 1950 To be pubhshed
Bum J H and Hutcheon D E (1949) Bnt J Pharmacol
4, 373 ^
Cannon W B , and lissik K (1939) Amer J Physiol 125
765
and Rosenbluelh A (1933) Ibid 104 557
and Undil J E (1921) Ibid 58 353
Elhott T R (1905) J Physiol 32 401 ^
JEngel A , and Euler 13 S v (1950) Lancet 2 387
Euler 13 S V (1946) Acta physiol scand 12 73
(1949) Ibid 19 207
and Hamberg 13 (1949) Ibid 19 74
and Hellner S (1951) To be pubhshed
and Hokfelt B (1950) To be pubhshed ^ ,
and Schmiterlow C G (1947) Acta physiol scand 13 1
Folkow B, and Uvnas B (1948) Ibid 1^365
Gaddum J H and Goodwm L G (1947) / Physiol 105
357
Goldenberg M Pines K L Baldivin E F Greene D G
and Roh C E (1948) Amer J Med 5 792
Goodall McCh (1950a) Nature Land 166 738
(1950b) To be published , .
Greer C M Pinkston J O Baxter J H and Brannon X 5
(1938) J Pharmacol 62 189
Holton P (1949) Nature Land 163 217
Holtz P (ireoner K and Kroneberg (3 (1947) Arch exp
Path Pharmak 204 228 „ ,
Humphreys R 3 and Raab W (1950) Proc Soc exp Biol
NY H 302
James W O (1948) Nature Load 161 851 ,
Kappert, A Sutton G C Reale A Skoglund K H and
Nylin G (1950) Acta cardiol Brux S 121
Langemann H (1950) Abstr Comm 18 int Congr Physiol
Copenhagen
Loewi O (1921) Arch ges Physiol 189 239
Melville K I (1937) J Pharmacol 59, 317 . ,
Moeller J , and Koppermann E (1950) Z KreislForsch 39
333
Nasmyth P A (1949) J Physiol 110 294
Norlander O (1950) Acta physiol scand To be published
Peart W S (1949) J Physiol 108 491 „
Stehle R L and Ellsworth H C (1937) / Pharmacol 59
114
Swan H J C (1949) Lancet 2 508
Tamler M L Tullar B F and Luduena F P (1948) Science
107 39
TuUar B F (1948) J Amer chem Soc 7* 2067
Miss Edna Jackson has been appointed a Deputy Chief
Nursing Officer of the Ministry of Health in succession to
Mrs E Harman who has resigned following her marriage
Miss Jackson s duties cover a wide field of public health
nursmg, particularly in relation to mothers and young
children midwifery home nursing and the preventive
health services of the local health authorities She was
previously Public Health Nursmg Officer in the North west
Region of the Ministry
Jan 20, 1951
AGGLUTININ ANTI S IN HUMAN SERUM
B JTmi
Medical Journal
109
AGGLUTININ ANTI-S IN HUMAN SERUM
H I COOMBS, MA, PhD, MD
ELIZABETH W IKIN, B Sc
A E MOURANT, MA, DPhil, DM
AND
GERTRUDE PLAUT, BA, MD
(From St Bernards Hospital Southall Medical Research
Council Blood Group Reference Laboratory Lister
Institute and the North London Blood
Supply Depot Barnet)
The antibody anti S was first discos ered by Walsh and
Montgomery (1947) in the serum of a puerperal patient
whose fifth pregnancy had resulted in the birth of a
macerated and oedematous 'oetus Her second child
had died ot haemolytic disease of the newborn , the
third and fourth pregnancies had ended in early mis
carriages Her serum was found to contain anti D
together with an unidentified antibody which aggluti
nated the red cells of 48 6% out of a total of 253
Australian individuals chosen at random The agglu
tinin reacted most strongly at 37 C , but was also active
at lower temperatures It did not sensitize cells to the
Coombs test
The corresponding antigen S was shown by Sanger
and Race (1947) to be very closely related to the MN
blood group system m a manner similar to the relation
between the C, D and E antigens of the Rh system
The simplest explanation of the experimental results is
that two genes, S and s exist and that either one or the
other is always very closely linked to each M and N
gene, thus giving rise to four possible chromosome
arrangements — MS Ms, NS or Ns Each individual has,
of course, two such chromosomes, and these would there
fore give rise to 10 possible genotypes or combinations
of two chromosomes as shown in the accompanymg
Table The red blood cells of any person possessmg
The ^^NS Phenotypes Based on o Paper by Race Sanger LanJer
and BerlmshaM (1949)
Genotypes in
Each Phcnot>pe
1
Reactions of Pheno-
type with Antisera
Full
Ph noiype
Symbol
(RacsetuI
1949)
Symbol
Used
n
this
Paper
Frequency
of Phenotype
lo British
Population
Aati
M
S
MSMS MSMs !
+
_
+
MMS
MS +
21/
MsMs 1
+
—
—
MsMs
MS-
V
MSNS MSNs 1
MsNS
+
+
+
MNS
MNS +
28/
MsNs 1
+
+
—
MsNs
MNS-
22/
NSNS NSXs ;
—
+
+
NN S
NS 4-
NsNs
“ '
+
NsNs
NS-
13/
944 persons comprises 140 Australians nearly all of Bntuh onsin and
804 English
either one or two S genes as m lines 1, 3 and 5 of the
table, are agglutinated by anti S serum Not all the
genotspes can be distinguished from one another by
serological means Each group of serologically indis-
tinguishable genotjpes constitutes a phenotype, of which
there are six one to each line of the table In the last
column are given the percentage frequencies of thepheno
types among 944 unselected English and Australian per-
sons as reported by Race, Sanger Lawler and Bertinshaw
(1949) One notable feature is that most English bloods
containing M also contain S while most N bloods do
not contain S All the observed facts with regard to the
distribution of the S antigen in the population as a
whole and to its inheritance in individual families can
be explained on the above mentioned theory that there
are two genes, S and s, which are very closely linked to
M or N (Sanger Race, Walsh and Montgomery, 1948
Race, Sanger, Lawler, and Bertinshaw 1949)
A second example of anti S was discovered by Pickles
(1948) m the serum of a mother who subsequently gave
birth to a stillborn infant As in the above mentioned
case, anti D was also present with the anti-S Three
weeks before parturition the titre of anti-S was one
Three weeks after delivery it had risen to 16, and six
weeks after delivery it was eight These changes in titre
suggest that the production of anti S m this case was
due to an immune reaction, and an investigation of the
blood groups of the family gave support to this theory
The ABO Rh, MNS groups of the family were as
follows
Mother
Father
Surviving child
Slillbom infant
A R"r
O R.R,
A Rh+
A Rh+
M S-
MN S+
M S-i-
Direct
Coombs test
positive
Further support for the suggestion that the production
of anti S in this case was the result of an immune
reaction is given by the finding that the antibody was
more active at 37 C than at 20° C It has been men
tioned above that this lessening of activity with decrease
of temperature was also found in the case of Walsh and
Montgomery (1947) and probably for a similar reason
In this case and the previous one the presence of anti D
prevents us from knowing whether anti S was m any
way responsible 'for the haemolytic disease of the
foetus
A third example of anti S was found by Cutbush
and MolUson (1949) following the transfusion of an
unmarried woman who had never been pregnant She
had received six transfusions of blood of unknown Rh
and S type without reaction, but after the seventh trans
fusion of similar y untyped blood she had a ngor and
was then found to be Rh negative Her subsequent six
transfusions were of Rh negative blood but she never-
theless had reactions after most of them and in one case
the transfused cells were very rapidly disappearing from
her circulation It was then discovered that, m addition
to the anti D contained in the serum of the patient, there
was also anti-S and thereafter transfusions were of
Rh negative, S negative blood Even blood of this type
was rather rapidly eliminated showing the presence of
yet another kind of sensitivity which was not fully
explained In this case the antibody sensitized S positive
cells to the Coombs test, a fact which is suggestive of an
immune origin It is also almost certain that some, at
least, of the first six transfusions consisted of S positive
blood, and as these gave rise to no reaction, httle if any
anti S could have been present in the patients serum
before the transfusions were begun It is moreover,
highly probable that anti S was the cause of the reac
tions which followed most of the transfusions from the
eighth to the thirteenth
An example of anti S unaccompanied by anti-D has
been described bv Race Holt, Gorius and Bessis (1949)
as occurring in the serum of a patient after numerous
transfusions for haemolytic anaemia The antibody
reacted equally well at room temperature and at 37 C
110 Jan 20, 1951
AGGLUTININ ANTI-S IN HUMAN SERUM
Buthh
Midical Journal
cdc/ede
MsMs
P-
Anci S absent
/ Patient
t Deceased not tested
Q Male
O Pemale
O Miscarriage
In another case of multiple'transfusipns investigated
by Collins, Sanger, Allen, and Race (1*950) The patient
developed a large number of antibodies, including anti S
and the Rh antibodies anti-E and anti C" Waller and
Race (personal communication, 1950) have found anti-S
together with the Rh antibodies anti C and anti-B and
several other abnormal agglutimns in the serum of a
male Negro who had received numerous transfusions
These two cases are similar to one described by Callender
and Race (1946) in which, following a series of trans
fusions, numerous antibodies were formed, which did
not, however, include anti S
Da Silva Lacaz, Ikin and Mourant (unpublished data,
1950) have investigated the serum of a patient who after
several transfusions died following
a haemolytic reaction Her serum
was found to contain anti C, anti D,
and anti S Molhson (1950) has
described the case of a woman
who after several transfusions and
several pregnancies, two of them
ending in stillbirths due to anti D,
had a clinically unaffected Rh-
negative babv with a weak posi
tive direct Coombs reaction The
mother was then found to have
anti-S as well as anti-D in her
serum
Rosenfleia and Vogel (personal
communication, 1950) have detected
naturally occurring anti S as the
sole abnormal antibodv in the serum of a routine blood
donor An account of this case will shortly be published
ThftMNS blood group system has recently been described
as a whole in some detail by Race and Sanger (1950)
Report of a Further Case
The authors have investigated the case of a patient who
was born in 1894 and married in 1915 She had four mis
carriages each at seven months in 1917 1919 1921 and
1923 One son was born in 1925 and is alive and well
Three of the miscarriages followed severe accidents and
were thought by the patient and her husband to have been
thus caused The patient said that the fourth was induced
by herself
Early in 1948 she complained of fatigue weakness
breathlessness and progressive numbness and coldness of
the hands She was admitted to Hill End Hospital
SL Albans on September 18 1948 The blood findings
were urea 120 mg per 100 ml serum protein 52 g
per 100 ml haemoglobin 22% Haldane red cells
1 800 000 per c mm white cells 7 800 per c mm On
account of the severe rnaemia it was decided to give her
a transfusion but attempts at direct matching showed the
presence of an unusual agglutinin in her serum This was
quickly identified as anti S but before compatible blood
could be obtained and administered she died
Serology
Shortly after death a considerable volnme of blood was
withdrawn from the heart and large arteries by means of a
syringe and needle The serum from this blood has been
a valuable source of anti S for testing purposes having been
distributed to many laboratories The absence of admixed
anti Rh greatly simplifies its use.as a testing reagent
Comparison of the reactions of the serum with the original
anti S serum of Walsh and Montgomery showed that their
specificity was identical The serum of our patient how
ever, reacts more strongly at room temperature than at
37 C The blood groups of the patient and her relatives
are shown in the diagram Since the hasband and surviving
child are S negative and careful inquiries have yielded no
to-
-Dt
CDeTcdt
MjNj
P~
S absent
A O
cde/cde
MSMs
P+
CDe/3e
MSMi
P-
IsAlS
CDe/c(le
MtMs
P-
Anti S Absent
5 ^
/ue cde/cdo
BC
cde/cdo
MSNs
P+
CDe/cD
or Cdo/cDe
MiM»
P+
O B
cde/cd#
MiKc
Ant) S pmseni
□ cDe/cde
MtNs
- P+
Blood groups of the patient s family All surviving members (except the patient) were
tested with anti Kell and anti Lua with negative results All of these who were of group
A or O were also found to be negative to anU Lea The absence of the S antigen from
the patient s red cells is deduced only from the presence of anti S In her serum
evidence that the patient had ever had a blood transfusion ^
and in view of the raised activity of the antibody at lower
temperatures it is probable that this patients anti S differs
from eight of the nine other known examples in being of
natural occurrence Although the paUcnt was Rh negative
(cde/cde) the anti S was not accompanied by anti D Since
D IS a very much stronger immunizing antigen than S and
since five examples are known of anti-S accompanied by
anti D or some other Rh antibodies the absence of anti D
in this case is further evidence that the anti S is not a
product of some immunization which does not appear in
the history of the case It can be deduced from the diagram
that in one at least of her pregnancies the patient was
exposed to the risk of immunization to the D antigen,
and in view of her husband s Rh genotype she must
have been exposed in ali her pregnancies to the possibility
of immunization to either C or D if not both
In spite of the probable spontaneous origin of the anti S
and of its apparent lack of relation to the clinical condition
it IS probable that if transfusion bad been attempted without
the very careful cross matching which was done a reaction
would have occurred
It may be noted that the other two antibodies associated
With the MNS system- — namely anti M and anti N — both
occur as ranties in human serum, and that m each case
some of the examples seem to be of spontaneous and some
of immune origin
At necropsy the body was that of a very obese woman
With generalized oedema and fluid in all cavities Large
vegetations were found on the mitral valve with old and
recent infarcts in the spleen and kidneys The latter were
small and death was ascribed to endocarditis and chronic
nephritis
The patients serum had unfortunately not undergone a
Wassermann test during her last illness or immediatety after
death When a specimen was tested more than a year after
death the result was equivocal No evidence of syphilis had
been found on post mortem examination The husband s
Wassermann reaction was negative
Genetics
The pedigree shown m the diagram does not account for
the presence of anti S in the patient s serum since neither
her surviving child nor any child by her husband could
have been S positive and so immunized her to the S antigen _
The fact that she was MN and made anti S shows that her
genotype was MsNs Since among her brothers and sisters
all the four combinations MS+, MS- MNS+ and MNS-
were found the genotypes of all of them can be deduced
as well as those of their parents The genotypes of MS- and
MNS- are bound to be MsMs and MsNs rcspeUively Since
homozygous MsMs is present m the children each parent
Jan 20 1951
AGGLUTININ ANTI S IN HUMAN SERUM
BunsH
Moical Jouhsal
Ml
must have had an Ms chromosome and the one who sup
plied the Ns chromosome to the children must ha\e been
MsNs To account for the MS+ child the other parent
must have been MSMs Thus the genoi> pes of the S positive
children must be MSMs and MSNs respectively The
patients husband is MsMs and their son who is MsNs
got Ms from his father and Ns from his mother
This family does not open up any possibilities of detect
mg cross overs between the MN and Ss loci but 123 families
have now been investigated without the detection of a cross
over (Race Sanger Lawler and Berlinshaw 1949) This
fact and even more strongly the maintenance in the general
population of an uneven distribution of S and s with respect
to M and N show that crossovers must be very rare and
the linkage between the loci must be comparable m close
ness to that between the C D and E loci on the Rh chromo
some When it was found that the antibody was probably
of spontaneous ongin it was thought that its occurrence
might be genetically determined The sera of the patient s
three S negative siblings were therefore examined for anti S
but none was found
Summon
A summary of previous work on the occurrence of anti S
in human serum is given Eight of the nine known examples
other than the present one appear to be the results of
immunization and seven of them contain some form of
anti Rh
A case is described in which anti S seems to have occurred
spontaneously and was discovered in a direct matching test
in preparation for a transfusion The serum from this case
has proved to be a valuable testing reagent for the S factor
Addendum
While this paper was in the press the serum from a fatal
transfusion reaction case was referred to the M R C Blood
Group Reference Laboratory it was confirmed that it
contained anli S and no other abnormal antibody
References
Callender S T and Race, R R (19461 ^rrn Eugfn 13 102
Collins J O Saticer Ruth Allen F H lun and Race R R
(19^0) British MfdicaJ Journal 1 1297
Culbush Mane and Mollison P L (1949) Lancet 1 102
Mollison P L (1950) Blood Transfusion m Clinical Medicine
Blackwell Sacniuic Publicauons Oxford
Pickles M M (19-8) I\aturc Lend 162 66
Race R R Holt H A Gnnus J and Bessis M (1949) C R
Soc Biol Pans 143 980
and Smper Rmh (1950) B^ood Groups m Man Blackwell
Scientific Publications Oxford
Lawler S D and Berunshxw D (1949) Heredity 3
205
Sanger Ruth and R-cc R R (1947) Haliire Loud 160 505
Walsh R- j and Monigomcry C (1948) Heredity
\\als^ R and MonlEomcry C M (1947) Nature Land
160 504
The Hampstead Health Institute wh ch the London
Count) Council is considering acquinne for conxersion into
a health centre under the National Health Service is a large
22 roomed house in an overcrowded district of Kilbum It
was founded in 1911 b\ the laic Mr Thomas Hancock Nunn
and is supported "b) pnvaic subscription and b) the rent
received from certain subtenants It runs two social clubs and
an old peoples club and dances are occasional!) held and
in addition it houses the local Citizens Advice Bureau Poor
Mans Law) cr S^AFA andHSA branch offices and the
Hampstead Asso'-ntion for Moral WcTare Work An LC C
maternitv and child welfare clinic is open four full davs a
week Dental aural and ophlhalm c clinics are held rtcu
lari) and classes for brcalhinc exercises and for squint
meet once a week The Minor Ailments Centre of the
Institute IS open every da) with a doctor present cverv
Wednesdav
THE EFFECTS OF HEXAMETHONIUM
BROmOE ON THE STOMACH
BY
A. H. DOUTHWAITE, MD, FRCP
Physician Guys Hospital
AND
M G THORNE, MD, MR CP
Medical Registrar Guys Hospital
The following is an account of a study of the action
of hexamethonium bromide (C6) on gastnc secretion
and motility which was undertaken in the light of a
paper by Kay and Smith (1950) Working with patients
suffering from duodenal ulcer, they found that a closely
similar compound, hexamethonium iodide inhibited the
spontaneous secreUon of hydrochloric acid to the point
of achlorhydria They also showed that the compound
mhibited the secretion of acid which normally occurs
m insulin induced hypoglycaemia but did not affect that
produced by histamine They noted too that the drug
induced a prolonged inhibition of gastric molilil>
For the purposes of our investigation it was decided to
use two routine and commonly practised tests — the
barium meal and the gruel test meal These tests were
chosen, first, because of the value for comparative pur-
poses of assessing_ the properties of new compounds by
previously tried methods secondly, because both these
tests afforded an opportunity of studvmg the action of
C6 on the full rather than the empty stomach, in contrast
to the work of Kay and Smith , and lastly because most
of the subjects employed were old cases who well knew
the routine tests and in whom undue apprehension
would therefore be avoided This was considered to
be important as the marked inhibitory effects that strong
emotions exert on gastric motility should be eliminated
so far ps possible
Effect on Gastnc Motility \
Ten patients were chosen Nine were males with clmi
cal and radiological evidence of duodenal ulcer and one
was a female without such evidence their ages ranged
from 16 to 56 years They were bed patients and
some had previously been treated with Lhyoscy amine
sulphate and alkaline powders but in no case were these
drugs given within 12 hours of the tests On the day
before the trial a test dose of 50 mg. of C6 was given
intramuscularly and the patient was observed in the
supine and erect positions so that hvpcr reactors could
be excluded from the subsequent experiments
Gastnc motility and emptying time wc'e assessed
radiologically by means of barium meals The patients
having fasted for at least 12 hours were given about
three quarters of a pint (426 ml ) of barium meal to
swal'ovv They were screened during the actual swallow-
ing of the meal kept under observation until it had
entered the duodenum and subsequently rc-exammed
radiologically m half an hour and if this was indicated
thereafter at hourly intervals In the intervals between
being screened the patients sat in chairs but the actual
X rav films were taken with the subjects in the erect
position unless they felt faint The points that were par
ticularly noticed dunng the examination were gastric
tone as revealed by the shape and perista sis of the
112 Jan 20, 1951
EFFECTS OF HEXAMETHONIUM ON THE STOMACH
Barmn
MojicalJournai
r
I
1
Fig 1 — Case 10 Control appearance oE the stomach immedi
ately after the swallowing of a barium meal
Stomach, and emptying time, as shown by the measure-
ment of the interval before the first appearance of the
meal in the duodenum and the appearance of the stomach
in the half hour and subsequen* films
All the subjects were first given control barium meals,
and nine out of the ten were shown to have highly
motile stomachs with active peristalsis and a consequent
rapid appearance of barium in the duodenum (see Table)
f-io 2 — Ca:>c 10 Coni ol half an hour after the banum
meal showme almon complete gasinc emptying the meal bcmg
distnbuted tlmoughoul the jejunum
Time Intervals Between the Taking of a Barium Meal and its
Observed Entry into the Duodenum
Case No
Control
ce
2
4 minutes
10 minutes
4
Immediate
10
5
4 minutes
5
8
Immediate
20 ^
9
30
1 3 6 7 10
/Differences between control and C6 too small
\ for assessment
The timing is approximate only because of the impracticability of keeping
the subjects under continuous screening
After half an hour nine of the ten stomachs had emptied
themselves of about four fifths or more of their con
tents, the tenth being half emptied, and the banum was
distributed throughout the jejunum, having traversed
the duodenum, leaving it nearly void of radio opaque
material (Figs 1 and 2)
Three days later seven of the subjects were given
100 mg of C6 intramuscularly half an hour before
receiving a barium meal No obvious difference was
noted in the shape of the stomachs immediately after
takmg the meal , but there was some diminution in
penstalsis, which was by no means completely inhibited,
however (Fig 3) In five cases there was, too, a notable
prolongation of the interval between the taking of the
banum and its apparent entry into the duodenum (see
Table)
The half-hour films differed remarkably from the con
trols In no case had the stomach emptied itself of
more than about a quarter of its contents The por
tion of the meal that had passed through the sphincter
was almost completely confined to the duodenum and
the beginning of the jejunum, which on screening
appeared as immobile dilated segments of bowel, so
loaded with barium that the. normal mucosal pattern
was obliterated (Figs 4, 5, and 6) Subsequent x ray
films revealed that this state of affairs persisted for
varymg periods of up to s« hours
Seven of the subjects were given repeated doses of
100 mg of C6 four times daily at four hourly intervals
for a period of seven days, after which the barium meal
was repeated All seven reacted in a manner similar to
that already described But a close study of the films of
Fig 3 — Case 10 100 mg of C6 given half houi him show
mg delaied gastne empiymg and the confinement of banum
to the first and second parts of the duodenum Although there
IS delay m emptying gastne penstalsis is present
Jav 20 1951
EFFECTS OF HEXAMETH.ONTUM ON THE STOMACH
Elxrnsn
^!cnICAL JOITLNAL
113
this senes revealed that in four cases the inhibitorj
effect was not so marked as it had been after the initial
experimental dose, though in onl> one subject was this
difference notable
Effect of C6 on Gastric Secretion
In this investigation routine gruel test meals were given
as controls to patients who had fasted 12 hours or more ,
and three days later these tt ts were repeated half an
hour after the administration of 100 mg of C6 intra
muscularly The test was performed on seven subjects
suffering from duodenal ulcer Six of these had high
climbing acid curses which were only slightly lowered
after the administration of C6 (Fig 7) In only one
subject was the C6 followed by achlorhydria, and here
the control meal had shown a low acid curse initially
(Fig 8) Emptying times were found to be slightly
prolonged but these results were not comparable to
those obtained svith the barium meals and were assessed
less accurately
Side-effects of C6
The most disabling side effects ssere those consequent
upon a loss in vascular tone Of the ten subjects six
fainted while standing erect drinking their barium meals
and the others felt faint These sensations xvere reheved
when the patient sat down or when the x ray table was
tilted to an angle of about 30 degrees to the horizontal
In addition three patients were rejected from the trial
because of their vigorous reaction to a 50 mg test dose
The onset of syncope was associated with a weakening
and sometimes complete obliteration of the radial pulse,
and was aceompanied by tachycardia
Fig *5 — 9 Conirol half houF film, «howan£ grcaicr pan
of meal m small mteslmc
I
Fig 5 — Case 9 lOJ mg of C6 half hour film Note the
retention of barium in stomach and duodenum
Comparatiae readings of the blood pressures of eight
patients were taken in supine and erect positions, with
and without C6 In no case was there significant altera
tion of the supine blood pressure when this was taken
three quarters of an hour after a single injection of
100 mg of C6 But in all cases in which an attempt was
made to estimate the blood pressure in the erect position
syncope ensued or threatened to ensue
All the patients noted transitory defects of visual
accommodation, and six felt dryness of the mouth
developing about 20 minutes after the administration of
C6 in addition four complained of a burning sensa-
tion in the eyes Those patients who were in a position
Fio 6— Case 9 S^ae as m Fig. 5 tuo hours later Th- meal
IS held baeJ: in Ihc duodenum and j-junum
114 Jan 20, 1951
EFFECTS OF HEXAMETHONIUM ON THE STOMACH
Brittot
Medical Journal
to make the comparison agreed that visual symptoms
and dryness of the mouth were not so pronounced
as when they had been taking l hyoscyamine sulphate
HOURS
F'O 7 — Average test meal values o£ seven patients with and With
out C6 Case 7 (Fig 8) was not included in this senes
> • I I 1 1 1 r
'A Vi % I I'A I'A PA 2
HOURS
Fig 8 — Case 7 Gruel test meal
curves with and without C6 demonstnt
ing the production of achlorhydria This
was the only case in the scries showing
such an effect
or belladonna Of
those who were
treated with C6
tor a week two
complained of oc
casional abdomi
nal discomfort
and nausea This
discomfort took
the form of a
bloated sensation
and anorexia
In general all the other side reactions became less
marked towards the end of the course of treatment,
though standing still in the erect position, as for the
estimation of blood pressure or for screening, still caused
famtness
Discaision
Kay and Smith found complete inhibition of peristalsis
for periods of up to four hours They were, however,
studying the empty stomach and not, as here, the loaded
one , and this may explain also the fact that we found
the free and total gastric acid levels httle altered, while
they noted a marked lowering of free acid in the resting
stomach and a modified response to insulin but not to
histamine It may be that we were primardy measuring
hormonal rather than vagal induced acid secretion, and
that the exact effect of C6 depends on the extent to
which the vagal factor is involved in the total secretory
response to gruel in any particular case Their results
show that C6 might be beneficial in suppressing spon-
taneous gastric secretion
There are however, the following possible drawbacks
to Its therapeutic use First, m all the subjects of our
experiments vasomotor side-effects of the drug when
given in doses of 100 mg intramuscularly were incapa
citating enough to make it unsuitable tor ambulant
patients Secondly after continued use C6 might lose
some of Its potency as an agent which inhibits gastnc
and intestinal motility Finally the effect on a duodenal
ulcer of an artificial duodenal ileus produced by C6
cannot be predicted with certainty for whtle diminished
peristalsis and relaxation of the bowel wall might well
have a beneficial effect distension of the duodenum
would probably be harmful The dangers of an associa
tion of duodenal ileus with ulcer were pointed out by
Hurst Rowlands Jones and Ryle (1926) who described
two such ulcers which perforated and three others which
remained resistant to medical treatment
Although the ileus artificially induced by C6 lacks the
organic obstructive element of the naturally occurnng
condition, it is difficult to be certain that the barium
meal arrested by C6 in the upper part of the jejunum is
not Itself acting as an obstruction Measurements of
mtraduodenal pressure should decide this pomt.
In general the disadvantages of C6 discussed above
come into operation only when the subject is ambulant
and taking food , thus its potentialities would seem to
be strongest for bed patients and for use at night
The experiments were not in the nature of a thera
pcutic trial, all the patients being without symptoms at
the time of the tests, and receiving orthodox treatment
Summary
C6 given in doses of 100 mg intramuscularly to 10
patients was found to delay the onset of gastnc empty
mg of a barium meal for periods of up to 30 minutes and
completion of emptying till the sixth hour
Gastric peristalsis was dimmished but not completely
inhibited, and there was Ob' change in the shape of the
stomach The small gut (particularly- the duodenum and
upper jejunum) was revealed to be dilated and immobile
for periods of up to six hours after the drug was given
Gastric secretion as revealed by the gruel test meal was
only slightly altered by C6 The patients in this tnal were
found to be much more susceptible to the unpleasant side
effects of the drug than those reported fay Kay and Smith
perhaps because they were bed pauents
The properties which C6 possesses suggest that the drug
may be of therapeutic value m the treatment of gastnc and
duodenal ulcer particularly in bed patients and at night.
We acknowledge with thanks the helpful co-ojieration of
Dr T H Hills director of the Department of Diagnostic
Radiology Guy s Hospital and his colleagues We express our
thanks also to Messrs May & Balccr Lid for the supplies of
hcxamethcmium
References
Hurst A F Rowlands R P , Jones J G and Ryle J A
(1926) Cu) s Hasp Jiep 76 162 ,
Kay A W and Smith A N (1950) British Medical Journal
1 460
At a meeting of the Zoological Soaety of London on
December 12 last Dr L Harrison Matthews showed slides
and a film to illustrate the account of an expedition to the
island of Ramsey to study the process of lactation in tlie
grey seal during September and October 1950 An adult
female seal was captured by means of a special net, and was
kept in captivity with her baby tor fifteen days Daily
weighings of mother and young were made specimens of
milk were taken for analysis and information on the
breeding and nursing habits of the seals was collected The
average daily gam in weight of the pup was 3 3 Ib the
weight increasing from 43 lb on the third day after birth
to 92 Ib on the eighteenth (the birth weight of the grey seal
IS about 30 lb ) The average daily loss in weight of the
mother was 6 3 Ib during the same period her weight
decreasing from 371 Ib to 276 Ib a total loss of 95 lb
Adult and pup occasionally drank small amounts (undeter
mined) of water both fresh and salt but the mother did not
feed dunng the nursing period Dailv weighings of a number
of pups at liberty showed that the growth rate of the captive
pup was nol affected by the conditions of captivity Analysts
of the milk (undertaken by Dr I R Rowland) showed over
67% solids with over 53% fats The captive pup was weaned
on the eighteenth day after birth and left the beach on the
thirtieth after it had completed the moult of its natal coat
Both adult and pup were surprisingly docile m captivity
Jav 20 1951 . ADDISONS DISEASE OCCURRING IN TWO BROTHERS
DxirKH
NtiDICAL Jol.Il.NAL
115
Not only is the number of reported cases small but
ADDISON’S DISEASE OCCURRING IN m most of them the esidence does not satisfy the modern
TWO BROTHERS
BV
J N BRIGGS, MD, MR CP
J r GOODWIN, MD, MRCP*
AND
A. WILSON, MD, PhD, FRTPSt
tr rom the Department of Phnrinacolos\ and Tlicrapeiittcs
Unit ersit} of Sheffield the Sht ffield Children s Hospital
and the Sheffield Iio\al Infirmary)
There are two aspects of Addison s disease on which
relatively little information is available one is its
occurrence in childhood (m all about 60 cases have
been reported) and the other concerns the role of
hereditary factors
It has periodically been suggested, especially when
this disease has occurred in several members of the
same family that the condition may be inherited This
hypothesis is perhaps plausible since there is evidence
that hereditary factors operate in other endocrine
disorders — for example diabetes mcliitus and the
Laurence-Moon-Bicdl syndrome In studying any such
relationships the two important features necessary arc
reliable criteria of diagnosis and an adequate supply
of clinical cases
Addison s disease is a relatively rare condition never
thcless several possible familial cases have been
recorded Fleming and Miller (1900) described a mother
who was quite well until her first pregnancy when she
became pigmented and asthenic Her condition showed
an exacerbation after each succeeding pregnancy One
child died at birth and the four remaining children
whose ages ranged from 2} to 7 years were all pig
mented and suffered from unexplained attacks of diar
rhoea and vomiting Unfortunately there was no
follow up or necropsy Groom (1909) described three
sisters who were pigmented and asthenic, but there
IS insutlicicnt biochemical evidence and there was no
follow up or necropsy in any of his three cases Wake
field and Smith (1927) presented the case of a man
aged 2S in whom necropsv revealed absence of the
riaht suprarenal Two of the man s brothers his father,
grandfather and a paternal uncle were all pigmented,
while seven other brothers were fair skinned but there
was no chmeal examination or follow up in any of these
relativ cs
In discussing Addisons disease in relation to heredity
Morabilo (1927) has drawn attention to a case in which
a brother and sister aged 7 and 10 vears rcspcc
tivclv became graduallv pigmented and in whom the
Von Pirqiet test was strongly positive In both parents
and children the Was'ermann reaction was positive He
attributed the pathology to congenital syphilis with
superadded tuberculosis Borghini (1937) reported the
case of a Hvearold Italian boy who was under
nounshed and subject to attacls of weakness on slight
exertion Tlie bov s mother apparentlv had died from
tvpical Addisons disease but after a five v car follow
up the child s general condition was unaltered and there
was no change in the pigmentation
Now nt ihe ro^pniiJL-te Medical School H ”'n'»rsnilh
Lerdon
+Now M Vnj\-cr^f' College Ho^ a! Mcdi'al School Lo’“don
criteria for the diagnosis of Addisons disease In his
c\tensi\c revievN of 566 reported cases Guliman (1930),
although doubtful whether heredit) pla>s an important
part in the genesis of the disease states that it can
not be dented that in rare instances there is a hcrcdilar>
tendency
In Mcw of the relative paucity of information on
this aspect of the subject it is important, now that
reliable diagnostic methods arc available, to investigate
thoroughly all cases in which the disease occurs in more
than one member of a family We have rcccntl>
observed two young brothers with Addisons disease
whose case reports follow
Case 1
A schoolboy aged 12 was ndmitted to the Sheffield
Childrens Hospital on July 30 1946 complaining of
lisllcssness anorexia loss of weight vomiting and
diarrhoea which had gradually incfcascd during the
previous three weeks The symptoms were nt first
asenbed by his doctor to an attack of gastro enteritis
but as there was no response to treatment the child was
referred to hospital His mother stated that since infancy
the boy had been very fond of salt and would often eat
this alone He had had measles chicken pox whooping
cough and mumps There was no family hisiorv of
tuberculosis abnormal pigmentation or Addisons disease
Apart from his brother there were no siblings
On admission the patient was very drowsy had inter
miitcnt attacks of retching and diarrhoea and responded
to questioning with difficulty He was markedly dehydrated
There was diffuse dark brown pigmentation of the face
back of the neck dorsum of the hands the forearms and
the extensor surfaces of the legs extending from the knees
to the ankles The buccal mucous membrane was not
pigmented
The apex beat was not palpable and by percussion the
heart was H (3 75 cm) internal to llie mid clavicular
line The heart sounds were faint and regular no mur
murs were heard The pulse rate was 120 a minute weak
but regular and the blood pressure was 80/40 There were
no abnormal features in the abdomen lungs or nervous
svMcm and no cosio lumbar tenderness He was of normal
stature but both testicles were undescended and 4he penis
was underdeveloped Apart from three carious teeth there
was no ojhcr evidence of any local infection
The unne showed no albumin or sugar ketones were
present there was no deposit examination of the blood
showed rSR 16 mm in one hour fasting blood sugar
50 me per 100 ml plasma potassium 2^ mg per 100 ml
scrum sodium 280 mg per 100 ml Robinson Power and
Kepler (1941) excretion test ratio A = 4^ haemoclobin
l(K)'* red cells 5 010 000 white cells 9 400 (neutrophil
polymorphs 6S monocytes 4% basophils I'i lympho
cytes 27 J^) Radiographs of the chest showed a small heart
shadow and normal lung fields (Tic I) The elcctrocardio
gram revealed sinus tachvcardia and low voltage curves
with S-T depression and flat T waves in all leads Radio
graphs of the abdomen showed two calcified glands in Ihe
region of ihc ncht iliac fossa The Mantoux test with
1/1 000 old tuberculin was positive
Immediatelv on completion of the invcstications adrenal
cortex extract ( cucortonc was given in 10 ml doses inlra
muscularU cverv six hours and DC A 5 mg every 12
hours Tlie following day supplementary salt (4 g six
limes a dav) was civcn and he drank fluids caccriv By
Aucust 5 there was a striking clinical improvcmcrt He
was alert and answered questions quicklv and accur-’lely
He ate his food caccrU and took an active interest in his
surroundincs The apex beat was now palpable ard the
pearussion note indicated an increase in cardiac dullness
116 Jan 20, 1951
ADDISONS DISEASE OCCUR.R1NG IN TWO BROTHERS
British
MsDICAI JOlKSAL
to the left The blood pressure was 100/74 and radio
graphs of the chest revealed a marked increase in the heart
shadow (Fig 2) The electrocardiogram was normal
On August 8 pigmentation was less diffuse and dark areas
were still apparent on the flexor surfaees of the forearms
and hands, along the vertebral column and anterior superior
pio 2 — Case t Chest radiograph after treatment The heart is
now normal in size
iliac spines and on the abdomen at the level of the trouser
belt There was no evidence of buccal pigmentation Blood
pressure was 100/75 On August 10 adrenal cortical extract
was discontinued and DC A reduced to 2 5 mg every 48
hours Supplementary salt therapy was continued The
next day he was able to walk unaided m the \/ard and his
general clinical improvement was maintained On August 19
the second Robinson-Power-Kepler test showed a value of
19 His blood pressure remained stationary at 102/72 and
he gradually increased in weight On August 30 a 25 mg
pellet of D C A was implanted by Mr Clifford Jones on
the right rectus sheath under local analgesia Two days
later intramuscular injections of D C A were discontinued
At this time the serum sodium was 315 mg per 100 ml
plasma potassium 21 mg per lOO ml and the Robinson
Power-Kcpler excretion test ratio A=25
He was discharged and referred for follow up as an out
patient He required a second implantation after three
months, and was then given 150 mg of DC A He has
had two further pellets of 150 mg of DC A the effects
of each lasted approximately seven months With this treat
ment he has for two years been adequately controlled and
IS able to attend school regularly and to walk distances up
to two miles without excessive fatigue His pigmentation
has increased m intensity and small areas are now preseni
on the soft palate His blood pressure remains at about
100/55 mm Hg
The 24 hourly unnary output of 17 ketosteroids was
5 mg and in view of his cryptorchidism chorionic
gonadotropin ( gonan ) was given intramuscularly, 500
1 U twice weekly for six weeks His penis increased in
size and six months hler both testicles were descended
Case 2
The elder brother of Case 1 aged 17 was admitted to
the Royal Infirmary, Sheflield on July 31, 1947 He had
been in good health until five weeks before admission when
he complained of epigastric pain and vomiting which lasted
24 hours One weel later he had a recurrence of the pain
while suffering from a septic great toe nail This was
removed by his own practitioner, but he had two further
attacks of abdominal pain and vomiting the second attack
leading to his admission to hospital Pigmentation of skin
and loss of weight had been noticed recently There was
no relevant past history
He was a veil developed youth with very faint generalized
pigmentation and a small area of pigmentation on the
buccal mucosa T here was slight dehydration The cardio
vascular svstem was normal BP 120/70, pulse 104 regular
Respiratory abdominal and central nervous systems were
normal His temperature was 97 F (36 1 C) A trice
of albumin was found in the urine Examination of the
blood showed E S R , 12 mm in one hour serum sodium
345 mg per 100 ml serum potassium 17 mg per 100 ml
NPN 60 mg per 100 ml Hb 103% red cells 5 250 000
white cells 5400 (polymorphs 53%, lymphocytes An
monocytes 3%)
A tentative di ignosis of Addison s disease was made, and
the patient was given liberal fluids and extra salt by mouth
This did not stop the vomiting so an intravenous infusion
of sodium chloride and 5% dextrose was set up
hours later he suddenly became extremely restless and the
pulse rose to 140 a minute There were no signs of pul
monary oedema and no abnormal signs in the central
nervous system The restlessness continued and the next
morning his condition had deteriorated well marked neck
rigidity and pyrexia had developed A lumbar puncture
showed a normal pressure and no block The fluid ivas
clear and normal His blood pressure was 125/65
In spite of continuous therapy with adrenal cortical
extract penicillin and intravenous glucose saline the
patient diad 72 hours after admission His pigmentation
had increased markedly during the last three days of his
life but the blood pressure remained normal until three
hours before death when the systolic pressure fell to 70
Jan 20 \95\ ADDISON S DISEASE OCCURRING IN TAVO BROTHERS
A postmortem examination Nsas mide b> Dr L C D
Hermitlc Both suprarenal glands ucrc atrophic and histo
locicd examination showed simple atroph> invol\ing maml>
the cortex (Fig 3) The ih>mus was considcrablj larger
than normal and
the thyroid gland
was also enlarged
the gonads and
pituitary body
were normal The
Iicart was small
and the lungs
were slightly
oedematous the
right lung having
SIX lobes and the
left lung four
There were no
other important
findings
It IS difficult to
account for the
sudden detenora
1 1 o n in this
patient s condi
tion and his failure
to respond to treat
ment* It IS possible
that the maintc
nance of a normal
blood pressure till
the terminal stages
of his illness was
due to the rela
live integrity of the
mcduilae of the
suprarenal glands The enlarged th>mus gland directs
attention to the possibilil) of m> asthenia gravis but there
was not at an> lime clinical evidence of this disease The
congenital abnormalil> in the lungs is noteworth)
Discussion
Because these two cases of Addison s disease occurred
in brothers their famil> histor> was carefully and
e\hausincl> investigated Both parents were health^
Thc> came from a large cit> and their families were
not m an> way related Tlicy had only the two children
The maternal grandparents died in old age and their
children were not pigmented though one son had a
wasting disease in childhood but recovered and was
lost at sea in the second world war No relevant infor
mation vvis available regarding the paternal grano
parents other than that the grandmother died at the
ace of 82 and that the grandfather is still alive and
well aged 7^ There arc several paternal cousins who
have not been traced but who at least until adult life
arc known to have been hcalthv
\Vc are of the op nton that in each patient the disease
was due pnmarilv to atrophv of the suprarenal glands
It IS not surprising that the voungcr brother had calcified
abdominal glands since he nad been tal mg farm milk
which was neither pasi-'iinzcd nor boiled
Tlic occurrence of such a rare d scasc in two brothers
and at an carlv age sucgesls the possibililv that a
ccncl c factor mav be involved
Summarv
Tlic h -n lire rc’atinc ;o po« bdiiv cf a familial
factor n addj^on^ di^c-'^e his been rev -“v ed The
oxiirrc''ce cf AdJivcn < di<- a'^e m tv^o bro b-r*; is d-«c*ab^
In ^e pilie^t who d cd atrophic supraren! c'ands a-'J
congenjlil abnormi! ics of tbe ’uncs v e-e found at
necropsy The cause of ihc disease in (lie two cases pre
scntcd IS considered to be primary suprarenal atrorh> In
view of the sugccstivc but inconclusive evidence afforded
bv this and other cases reported vse consider that the
familial and genetic aspects of Addison s disease merit
further study
We wish to thank Professor E J Wavtie for permission to
publish thc-c cases and we are grateful to Dr L C D Hcrmiltc
for his report on the necropsy findings in Case 2
Reftrences
Borghini G (1937) G Clin ined 18 43S
Crooni D 11 (1909) Lancet 1 603
I leming R A and Miller J (1900) British Mcdicnl Journal
1 1014
Guttman P H (1930) Arch Path 10 742,
Morabito F (1927) Pedtatria 35 969
Robinson F J Powxr M H, and Kepler E J (1941) Proc
Mayo Clin 16 577
W'akcficid E G and Smith E F (1927) Aruer J wr t Si
174 343
THE ELUORESCCNCC PHENOMENON OF
THE TONGUE
BY
\V TOMASZnVSM, M D Pornan, PhD
(From the Department of Therapeutics Clinical Lahorainr\
Roittt Iiifirtnary Cdinhiirgh)
When the mouth is \ievsed under ultra violet light
screened with Woods glass a reddish orange (luor
csccncc IS often \isiblc on the dorsum of Ihc longue
and sometimes on the teeth This fluorescence has
been recognized for some time and has been proved
to be due to the production of porphyrins by oral
micro organisms So far however, this fluorescence
has not been adequately studied m relation to the
various changes m the tongue that arc known to result
from nutritional deficiencies
Several authors have described this phenomenon
Derrien (1924) noticed fluorescent points in dental
cavities which he attributed to decomposition of
haemoglobin by bacteria The fluorescence of the
carious teeth or of tartar must be distinguished from
that of health) teeth in eases of congenital porphjrn
as first described bv Mackey and Garrod (1925-6)
Hvmans van den Bergh (192Sa 1928b) described this
lluorc'cencc of the tongue in greater dclail and
endeavoured to explain its aetiology but he did not
study Its clinical significance More recently Costello
and Luttenberger (1944) attributed the ab'cncc of the
normal fluorescence to vitamin B deficiency Accord
ing to them it is intense in children but Ics marked
m well nourished adults
Hagerman and Hirschfeld (1947) e'amin'd over 5'K)
patients in a dermatological clinic In about 60% of
their patients the fluorescence extended over the whole
tongue or covered about half of the dorsum which
was considered to be normal About every fourth
patient showed fluorescence over the whole surface
Toniucs showing absent or very limited fiuorcsccncc
were regarded as abnormal These authors found that
patients showing absent or grcallv diminished fluoi
cscencc often suffered from the si in lesions usuahy
associated with vitamin B dcfiacncv Thev noticed
also that vitamin B p'cparations csp'cially those con
taming panto heme acid u uallv produced a change to
Ihc normal fluorescence (Bnrish Mce'ical Journal f9-,9;
118 Jan 20 1951
FLUORESCENCE PHENOMENON OF THE TONGUE
Ewnsa
5feDICAL JoURNAi
Red fluorescence due to porphyrin is encountered in
other parts of the human body, both in health and
in disease It has been seen in sebaceous comedones
(Bommer, 1927, 1929) as bright-red points on the nose,
around the lips, etc Red fluorescence is often present
in the menstrual and lochial discharges (Jones, Figge,
and Hundley, 1944) probably due to porphvnn pro
duced by bacterial decomposition of blood It usually
disappears a few days after menstruation The tumour
chloroma contains an excessively large amount of
porphyrin (Thomas and Bigwood, 1935) Necrotic
tumours (Pohcard 1924) and many necrotic non
malignant tissues also exhibit red fluorescence
Method
Over 400 patients in medical wards and in the
blood clinic of the Edinburgh Royal Infirmary were
examined for fluorescence of the surface of the tongue
and teeth An ordinary ultra violet lamp with Wood s
glass was used
Diseases characterized by changes in the tongue were
specially selected, and, for comparison, examinations
were' also made in various other diseases and m a
number of healthy people of different ages In each
case a rough sketch of the surface of the tongue was
made Besides ordinary data concerning age, sex,
disease, etc , a short nutritional history was taken
In some cases antibiotics, vitamins, and chemothera-
peutic agSnts were given in order to investigate the
influence of these substances on the fluorescence
Appearance of the Tongue under Ultrn-nolet Light
The majority of healthy persons show fluorescence on
the. posterior half or three-quarters of the tongue s sur-
face The rest of the surface, especially the anterior
part, often has a greyish or whitish tinge Only about
20% of healthy persons exhibit fluorescence on the
whole tongue The margins and the tip are as a rule
free The fluorescence has usually a red or orange hue
but It often has a pinkish or yellow tinge Its intensity
\aries considerably m different persons
Observed through a magnifying glass, the fluor-
escence, which to the naked eye seems to be
coalescent, is seen to be composed of small fluor-
escing points corresponding to the filiform papillae
The material scraped from such a tongue is com
posed of bacteria epithelial cells, and particles of
food and on naked eye observation under ultra violet
light shows a pinkish or red fluorescence
Slightly coated tongues usually have a faint pinkish
fluorescence Intense red fluorescence is often associ
ated with a thick coating Tongues which do not exhibit
red fluorescence have sometimes a quite normal appear
ance under ordinary light
In a few persons small non fluorescing lacunae are
found on the red fluorescing area These lacunae have
a tendency to enlarge eccentrically in the course of
time In tongues with deep fissures red fluorescence
can sometimes be noted
It IS difficult to make an arbitrary distinction between
normality and abnormality according to the extent of
the area of fluorescence as has been attempted by
Hagerman and Hirschfeld Our clinical material was
divided simplv into cases m which fluorescence was
entirely absent and those in which it was present even
to a very slight extent The former vveie classified as
negative the latter as positive
Appearance in Healthy Individuals
For control purposes over 200 healthy persons of
both sexes and various ages vyere examined The
examination of children was mainly carried out in the
Princess Margaret Rose Orthopaedic Hospital Edm
burgh Apart from their orthopaedic disabilities, the
children were normal Subjects over 60 years of age
were selected mostly from inmates of Queensberry
House for the Aged, Edinburgh
The climcal material was divided into age groups Of
the total number examined, 59% were males and 41%
females but as sex seemed to exert no obvious influence
on the incidence of the fluorescence phenomenon males
and females were considered jointly Their nutritional
history did not reveal any evidence of deficiency The
results are given in Table I which shows that absence of
fluorescence increases steadily with age
Table I — Fluorescence m Healthy Indt\ iduals
Age Groiip
■ Total I
No
I
, Fluorescence of Tongue |
1 7
j Without
4 -
, - i
0-20 years ,
71 1
63
8
U
21-40 *
50 ]
44
6 !
12
41-60 '
40 1
33
7 1
I n
61-80
38
28
10 1
26
81-100
15 1
7
8
53
Total
214
175
39
, IS
In general, the intensity of the fluorescence in old
people was definitely less than m children and younger
adults There were often slight atrophic changes in the
filiform papillae in old people, but even in apparently
normal looking or coated tongues the fluorescence was
often absent
Fluorescence in Certain Diseases
Special attention was paid to diseases wl^ich are
associated with changes m the tongue
Fermcioiis Anaemia — ^Altogether 87 cases of pemiciouv
amemia were examined Most of these were well controlled
cases that had been treated with liver some of them for
many years or recently with vitamin B, Therefore most
of them had normal or nearly normal haemoglobin levels
Only six untreated eases were examined all showed com
paratively low haemoglobin levels The results of the exam
inations are given in Table II
Table II —Fluorescence of the Tongue in Cases of Pernicious
Anaemia
Age 1
j No of Cases 1
No Without Fluorescence
21-40 vea s
i
4
41-60 j
1 34
18
61-80
1 47
1 34
Total j
j 87
1 56 (64/>
Of the total number examined 64% were negative The
fluorescence in (he positive cases was_ mostly faint Com
pared according lo age groups the pernicious anaemia cases
show a much higher incidence of negative cases than the
normal persons Cases with a completely atrophic smooth
tongue were all negative though some of them had
haemoglobin values of over 100% '
It IS not known whether any fluorescence was present
before ireatmeni in these cases Examination of the six
untreated cases five of which were negative throws some
light on this problem On treatment the somewhat atrophic
Jan 20, 1951
FLUORESCENCE PHENOMENON OF THE TONGUE
Bxrmji
MnjtCAL Joui!-*aL
119
tongues of four of them showed some grow-th of their short
and atrophic papillae After a few weeks the surficc
acquired a delicate whitish covering, and two of the patients
previously entirely negative developed slight fluorescence
It wems therefore that liver Iherapy can in some cases
resi re the fluorescence but treatment of patients with
adv ,nced atrophy of the tongue does not restore the filiform
papi lae or the fluorescence The number of untreated eases
w i however too small for any dogmatic conclusions to
be drawn
Hypochromic Iron dcficicnr, Anaemia — For. comparison
a ^ up of patients suffering from iron deficiency anaemia
of iiiTerent ongin but mostly nutntional were examined
As well known this type of anaemia is often associated
wii atrophic changes of the filiform papillae It is also
kii *n that iron therapy frequently restores the condition to
n I il Altogether 28 patients were examined— 22 women
a 1 n men Their ages varied from 28 to 70 years the
\ ge being 46 Of the 28 examined 17 (dO^o) were nega
1 In general the pdsitive cases in this group showed a
sti cer fluorescence than those in the group of cases suffer
iiu 'rom pernicious anaemia In one negative case which
w t observed before and after treatment restoration of
p ; I ac and faint fluorescence followed improvement in the
il loglobin level and in the general health but in cases
wi permanently atrophic tongue the restoration of normal
ha I oglobin values did not produce any fluorescence
S ue Syndrome — Fifteen patients suffering from the
spr le syndrome three being children with coeliac disease
wen- examined The average age of this group was 33
The majority showed an atrophic tongde or had soreness
of the tongue they were all undergoing treatment Eleven
patients (73%) were negative The four positive cases had
been treated for several years with liver folic acid and
other compounds of the vitamin B group In these four the
tongue approached the normal in appearance and there was
a slight fluorescence
Other Diseases — Small groups of patients suffering from
other diseases were also examined Castro intestinal diseases
are often connected with lingual changes Out of 22 cases
of gastric and duodenal ulcer with an average age of 43
nearlv half showed absence of fluorescence On the other
hand cases of gastritis with heavily coated tongues usually
showed an orange or a peculiarly yellow fluorescence The
results in a group of patients with an unusual appearance
of the tongue are of some interest Three cases with hairy
tongue were negative Seven cases with marked brown
coloration of the coating of the tongue were all negative
and in two the fluorescence appeared after a few days treat
ment with nicoUnic acid Twelve cases of so<alIed scrotal
tongue (lingua scrotahs lingua plicata) characterized bv
numerous deep furrows were mainly negative In a group
of seven cases which showed signs of vitamin B deficiency
particularly of ariboflavinosis and characterized by angular
stomatitis and red smooth tongues fluorescence was absent
Groups of cases of diab'tes leukaemia and other diseases
did not give any conclusive results
Factors Influencing Fluorescence
Observations were made on patients treated for
various reasons walh antibiotics in order to study the
effect of these drugs on the fluorescence of their tongues
which was positive in cverv case before the beginning
of treatment In addition a number of healths per-
sons with sironglv (luorcscinc tongues were selected for
investigation of the local action of penicillin and other
antibiotics on the fluorescence
Penicillin vvas given in 500-unit lozenges (8-10 a dav)
to 5 persons After a few davs the fluo csccnce dis-
-appeared complc civ m each case starting from the
front and movang towards the back of the tongue In
three persons a brown colour of the tongue appeared
with some soreness of the dorsum With the cessation
of penicillin treatment the red fluorescence reappeared
gradually m a few days starting from the back of the
tongue Penicillin given intramiiscularlv to four per
sons 500 000 units daily for one week, did not abolish
the red fluorescence
Spcciallv prepared streptomvein lozenges (50 mg pci
lozenge) were given to three persons in a dosage ol
seven to eight lozenges a day for one week In all
three the fluorescence disappeared in four to five
days
In five patients treated with chloramphenicol (2 g
a day orally) for various diseases the fluorescence
vanished rapidly and at the same time the normal
coaling of the tongue disappeared Glossitis and signs
closely resembling ariboflavinosis developed in two of
them
Specially prepared chloramphenicol lozenges (5 mg
per lozenge) administered to three healthy persons in
a dosage of 10 lozenges daily for a week brought about
the disappearance of fluorescence in five to six days
Similar results were obtained in three patients treated
for various reasons with aureomycin, 2 g a day
orally Trials were also made with aureomycin lozenges
(5 mg per lozenge) on three healthy persons It vvas
found impossible to evaluate the local action of aurco
mvcm on the fluorescence during treatment as this sub
stance itself produces a bright yellow fluorescence which
covers the whole dorsum However with the cessation
of the treatment the fluorescence which had prevaously
been strongly positive, remained negative for two to
three weeks
In contradistinction to the cITcct of the antibiotics,
the use of sulphathiazole lozenges six a day, seemed
to have no cllect on the fluorescence phenomenon
Observations were also made on the effect of folic
acid riboflavin and nicotinamide on five patients with
signs suggestive of vitamin B deficiency and with
absence of fluorescence In three of them in whom
definite regeneration of the papillae took place a slight
fluorescence developed
As has been mentioned reappearance of fluor
csccnce was observed in some patients with pernicious
anaemia after treatment with vitamin B,, and the same
phenomenon was noted in cases of sprue syndrome
treated with folic acid nboflavin and nicotinic acid
and in cases of brown tongue treated with nicotinamide
Pantothenic acid has some influence on the intensity
of fluorescence In healthy persons with faint fluor
csccnce treatment with pantothenic acid 50 mg three
times dailv for two weeks, produced a marled increase
in Its intensity
Discassion
There is no doubt that this fluorescence is due to the
production of porphvrin bv penicillin sensitive micro-
organisms We do not know whether the porphyrin is
svaithesized bv the bacteria or whether it is the product
of decomposition of haemoglobin derived from food
or from the host Nor do we know the exact tvpe of
bactenum (or bacteria) concerned in porphvrin p oduc
tion in the mouth Carriif (1934) expressed the opinion
that the normal fluorescence of the tongue and of
comedones is due to a particular Gram positive bacil
lus He claims to be able to cultivate this porphyrin
120 Jan 20, 1951 FLUORESCENCE PHENOMENON OF THE TONGUE bmtob
— Medical Joxdinai
producing bacillus in special media— Sabouraud and
Fmk media — but we have so far been unable to
reproduce these results
The actual role of porphyrin in the metabolism of
the oral bacteria is also unknown Pappenheimer (1947)
suggests that porphyrin, at least in the diphtheria bacil
lus, might be produced in certain conditions in the pro
cess of synthesis of some respiratory enzyme, probably
cytochrome b
From the clinical point of view it is of interest to
inquire why this porphyrin production is absent in
certain normal and pathological conditions, and what
IS the part played by the vitamin-B group in its pro
duction It seems that at least two factors are
responsible for the fluorescence phenomenon (1) the
presence of porphyrin-producing bacteria , and (2) the
presence of normal papillae, since a smooth tongue
does not, as a rule, exhibit fluorescence Judging from
the fact that in a certain percentage of healthy and
adequately nourished persons the normal looking tongue
does not show fluorescence, some other factors must
also be responsible We do not know why the percent-
age of negative cases in healthy persons increases with
age
It IS doubtful whether the absence of fluorescence is
of value as a clinical sign of vitamin B deficiency, as
has been suggested by certain authors Some vitamin
deficiencies, especially those of nicotinic acid, riboflavin,
and aneurin do produce lesions of the tongue and
raucous membranes In such cases where glossitis and
atrophic papillae exist the absence of fluorescence is
understandable There is, however, no proof that
reduced or absent fluorescence is always due to
deficiency of the vitamin-B complex
Factors such as vitamin Bu, folic acid, vitamin-B
complex, apd iron seem to have some influence on
the restoration of fluorescence in certain conditions,
doubtless duq to their action in regenerating the
papillae In addition, the possibility that vitamins, as
growth factors, have some action on the bacterial flora
Itself cannot be excluded Mallinckrodt-Haupt (1938)
reported a stimulating influence of vitamins notably
aneurin and riboflavin, on porphyrin production by
bacteria in \itro '
The pathological states here investigated — pernicious
anaemia, sprue syndrome, and iron deficiency anaemia
— are often associated with nutritional disturbances, and
all are commonly characterized by lingual lesions
Brown (1949) and others brought about the disappear-
ance of lingual lesions in pernicious anaemia and
steatorrhoea by the admmistration of calcium panto-
thenate, inositol, nicotinic acid folic acid, riboflavin,
and hver extracts Good therapeutic results were
obtained in cases of glossitis in pernicious anaemia
by treatment with pure vitamin B„ (Stone and Spies,
1948 Schieve and Bundles, 1949) '
There is no explanation why so many cases of
pernicious anaemia, well controlled with liver and
vitamin B complex and showing an apparently normal
tongue, still failed to exhibit fluorescence Perhaps the
porphvrin-producing organism was not present in the
bacterial flora Until this organism is^ identified the
question cannot be properly answered
Nothing defimte can be said at present about whether
the fluorescence phenomenon is only a clinical curiosity
or whether it has some value as a guide to the state of
nutntion in the indiiidual Nor is anything known
about the significance and ultimate fate of the por
phyrin produced in the mouth It is reasonable to
assume that at least some of it accompames the
digested food to the lower part of the alimentary
tract
In addition, the role | of the normal bacterial flora in
the mouth remains unexplained We know very little
about the function of bacteria m the digestive tract of
man and their influence on the nutritional state of the
individual . Recent experimental work has opened a
new chapter in the role of bacteria m nutrition
(Elvehjem, 1948 , Johansson and Sarles, 1949) Lastly,
an interesting hypothesis has been put forward bv
Frazer (1949) on the part played by the bacterial flora
in the sprue syndrome and in pernicious anaemia The
importance of the intestinal bacterial flora in pernicious
anaemia was stressed long ago by Davidson (1928) It
IS also known that a number of vitamins are synthe
sized in the intestinal tract, but, conversely, certain
sulphonamides and antibiotics given orally may destroy
the intestinal bacteria and change the microflora of the
tract
' « Summary and Conclusions
The dorsum of the tongue often shows under Woods
light an orange red fluorescence This is probably due trt
synthesis of porphyrin by micro organisms
The tongue has been examined in over 400 persons
Fluorescence has been found in the majority 'of healthy
individuals
Absence of fluorescence becomes more frequent with
increasing age it was found m only 11% of children but
in 53% of people over 80
In certain diseases — pernicious anaemia, hypochromic
anaemia sprue syndrome and vitamin B deficienaes — there
IS a higher incidence of absent fluorescence
The vitamin B ^oup and iron have some influence in the
restoration of fluorescence Antibiotics destroy fluorescence
by their action on microflora
The clinical significance of this phenomenon is not yet
known Its possible connexion with nutritional factors has
been discussed
This work was earned out with the help of a Whaitt Kesearch
Scholarship from Edinburgh University mainly m the wards of
Professor D M Dunlop The antibiotic lozCnges were specially
prepared by Messrs Duncan, Flockhart and Co , Edinburgh, to
whom 1 wish to express my thanks
1 '
References
Bommer S (1927) Kim tVsehr 6 1142
(1929) ,4c/o derm venereal Stockh 10 391
British Medical Journal (1949) 1 672
Brown A (1949) British Medical journal 1 1073
Cami C (1934) Derm Z 70 189 , ,
Costello M J and Luttenberger, L V (1944) NY St J Med
44 1778
Davidson L S P (1928) J Path Bad 31 557
Derrien E (1924) C R Soc Biol Pans 91, 634
Elvehjem C A (1948) Fed Proa 7, 410
Frazer A C (1949) British Medical Journal 2, 769
Hagerman G and Hirschfeld R (1947) Acta derm venereal
Stockh 27 369
Hymans van den Bergh A A (1928a) Lancet 1 261
(1928b) Dtsch med Wschr 54 1492
Johansson tC R and Sarles W B (1949) Bact Rev 13 25
Jones E O Figge F H J and Hundley J M (1944) Cancer
Res 4 472
Mackey D and Garrod A E (1925-6) Quart J Med 19
. 357
Mallinckrodt Haupt A S (1938) Z Vitamlnforsch 7 303
Pappenheimer A M lun (1947) Fed Proc 6 479
Poheard A (1924) C R Soc Biol Pans 91 1423 , ,
Schieve J F and Rundles R W (1949) J Lab dm Med
34 439
Stone R E and Spies T D (I94S1 Ibid 33 1019
Thomas J and Bigwood E J (1935) C R Soc Biol Paris
118 381
Jav 20, 1951 HAEMANGIOMATOLiS NAEVI AND THORlU.Nt \
TREATMENT OT HAEMANGIOMATOUS
NAEVI WITH THORIUM X
ny
R E. BOWERS, MD, BSc., MR.CP
Assmant SHn Department St Thomases Hospital
! insighlly nature of hacmangiomatous nacvi of the
causes much distress anJ makes the patients or
parents seek treatment in almost all cases The
> t of this paper is to assess the results likely to
r tamed ssith thorium X in the treatment of capillary
and to make certain observations regarding the
ation of this method
Nalunl Hrstorv of Hacmangiomati
ore considering how or whether these naevi
nd to treatment it is necessary to take into account
'ossibility of spontaneous resolution and for this
isc It IS convenient to divide them into two common
tics — the flat and the riiscd Histologically, the
I I port Wine ) haemangiomata arc composed of
id capillary like vessels while the raised (straw-
ti ) lesions contain not only dilated capillaries but
a' many large intercommunicating blood filled spaces
wi h give them the name of cavernous naevi Many
o( iicse raised lesions contain both superficial and sub
Cl t meous elements or they miv be purely subcutaneous
bill apart from their position in the skin, the two
varieties of cavernous naevais appear and behave the
sail c in every respect,
Ihc so-called spider naevi arc really very small
haemangiectases, sometimes of toxic origin as in liver
disease They are not true naevi
I xcept for the faint reticular lesions of the glabellar
and nuchal regions, which often resolve spontancouslv
(Ai cy 194-Ja), the flat capillary naevi arc ncarlv always
persistent hence they arc often seen in adults
By contrast, the raised (cavernous) naevi carry quite
a different prognosis It was reahred for many vears
(Stclwagon 1902 Jadassohn 1932a) that complete
spontaneous resolution was a possibility later it was
shown by Lister (193S) and confirmed by many other
observers that the great majoritv resolve spontancouslv
bv the ace of 5 or 6 — a happv outcome which differs
from that of manv forms of treatment in that it is
unaccompanied bv anvihine more than the faintest
scarnng The ordinary caverno s lesions are never seen
in adults It is not proposed to discuss their treatment
here but the above remar) s do not mean that active
thcrapv is never desirable
Some haemanciomata remain fiat for a time but
become raised by the third or fourth month of life
these resolve spontancouslv m the same wav as the
ordinarv cavernous naevi Thev provide however a
possible source of error when one comes to assess the
usefulness of a given Ireatm-nt for when the child is
first seen the naevus mav be noted as " fiat o-
"capillan Us sub'eqi cm disappearance is rcco'ded
as the si,-cc"ful treatmeat of a capif’arv naevais
whe eas it is ro hinc iro'c than the sp-satareous cu'c
of a cavernous growth vvbich m ics ea best stages
appealed fiat and who'e iricmaediate raised s-age was
no. ebse-ved
Vpat from cerfaia ram g*oa'‘-s ro' r''c"jo-'\3 be'e,
them are two o„ sa-dre cxcep lo-s 'o the ge-rml ru’e
that the raised haemanciomata disappear spontancouslv
Both conditions arc uncommon, and both usually
involve large areas of skin The first is the extensive
slightly raised deep red stain on the side of the face
which often covers an area roughly corresponding to
one or more divisions of the trigeminal nerve it mav
even bear pedunculated excrescences Tins tvpc is
just as persistent as the ordinary port wine slam
It IS sometimes part of the Sturge-Weber svndrome
(naevus, buphtlialmos, pial angiomatosis and cerebral
calcification on the same side, with contralateral hcmi
picgia and often mental defect and epileptic fits)
The second exception is the large spongy nised naevus
which sometimes appears to be composed of varices
and may bear areas of hyperkeratosis It is very
unsighllv, IS cxlrcmclv difiicult to treat and may be
accompanied by haemangiomata elsewhere than in the
slin the underlying bones may he greatly rarefied
In the ease reported by Silverman (1946) the patient had
also a paraplegia due to an extradural haemangioma
that author mentions several other eases in the literature
J idassohn (1932b) and Ewing (1940) say that the expan
Sion of such cutaneous naevi may do serious damage
but this must be a very exceptional occurrence
Treatment
Treatment of ‘port wine stains has been and in
many eases still is, very unsatisfactory, nearly all the
common methods m use before the introduction of
thorium X produced scarring or worse and thorium X
was welcomed ns a practicable and apparently safe treat
ment for these lesions Scholtz (1937) recommended it
for this purpose Prosser Thomas (1 939) reported favour
able resutts in an unanalyscd senes of 50 eases, and
similar reports, but dealing only with one or two
patients, came from Corsi (1943) and Feeney (1944)
1 have been unable to trace my large series of cases
treated in this way
Tliorium \ is a radioactive substance whose prepara
tion and properties were described by Lomholt (1923
19j6) and more rcccnllv reviewed by Prosser Tliomas
(1945) It IS sufiicicnl to say here that it has a half
decay period of 3 64 davs emiltmg alpha particles o'
such small penetrating power that when it is applied
to the surface of the s) m m alcoholic solution its effect
IS demonstrable histologically for a distance of only
0 2 to O' mm beneath the surface Its effect is ven
similar to that of a small dose of poorly p~netraling
t rays short lived vascular dilatation progresses, after
repeated doses to an obliterative endangiins the possi
biiitv of senous skm damage is very small but is
cons dered below
Prevent Sludv
l-ate in I9->7 1 began to review all available cases of
hacmangiomatous naevus treated v ith thorium X at
St Thom’S s Hospital The mveslieation was originally
undertak'-n at the sucecstitn of Dr E W Pros’er
Thomas n order to study the poss b'e octu'rerce of
rad oJcTnatitis o- atrophy , but it «oon became e ideal
as manv others have dsccvcrcd that the effects of
iho'um \ oa these nae i are vanab'e in the extreme
some pati'nls b-iag apparc-th cu'ed, vvhile oi'en
receive little O' no brae't
The r^t tncs and tb-ir -ccords wc*c ihercfo-e re-
exaran-d la the hope of f-di-ag fo) the response to be
cxpr» eJ from the .'ea.r-'"! of va- o s ’.pcs of aacais
122 Jan 20, 1951
HAEMANGIOMATOUS NAEVI AND THORIUM X
Burma
Medicai. Jouilkal
and (6) the point at which treatment of unsatisfactory
cases should be abandoned as unlikely to produce
further improvement
Mfftenal Available — The records of 48 patients with
naevi treated with thorium X since 1939 were available
^Four of these were not complete enough for analysis,
nor could the patienjs be traced by letter , they 'were
therefore omitted from the study The remammg 44
were mostly seen by me personally
Methods of Treatment — In most cases thorium X
m alcohol, 1,500 ESU /ml, was applied by a slight
modification of the technique recommended by Rox-
burgh (1947) The erythema produced was allowed to
subside and was followed about a week later by the
next application, the interval between treatments being
usually three to four weeks In some patients col-
lodion was applied after painting, or the interval was
reduced to two weeks or even one week when less
mtensive ^treatment had failed , but, apart from an
increased incidence and degree of erythematous
reactions, the ultimate results seemed no different
Radiodermatibs and Atrophy
The possibility that these two ill effects might follow
paintmg of the skin with thorium X has been suggested
m the literature, but there is considerable uncertainty
about their incidence, or even whether they occur at all
in the dosage usually given (Airqy, 1944b , Feeney,
1947 , Forman, 1948)
Several authors state that they have seen a little thin-
ning and atrophy of the skin as a result of treatment
with thorium X, but these statements must be accepted
with reserve, as this degree of skin change often follows
the spontaneous disappearance of an untreated
cavernous naevus
In the present series no serious damage was seen
which could be attributed to the thorium X The largest
number of paintings recorded was 109 in about four
years m this case one part of the treated area became
pigmented One child, after 81 paintings spread over
seven years, had questionable atrophy of the skin, with
absent lanugo hairs on two small areas , one had a shiny
and scaly appearance of the skin after about 63 paintings
given over three and a half years but this child was
a congerutal ichthyotic Two children had definite
atrophy — one with pigmentation — after 16 and 24 paint-
ings (Cases 3 and 17), but each of these hadliad carbon
dioxide snow as well in view of the small amount of
thonum X given, and the large amount used with
impunity in other cases, it is probable that the carbon
dioxide was responsible for some or all of this damage
A boy (Case 30) developed stippled brown pigmentaUon
after 54 treatments m two years
It is not unusual to see a shiny appearance of the
skin after repeated treatments Under the skin-
microscope this appears to be due to hyperkeratosis
m my experience it is reversible in its early stages,
though no doubt it indicates the need for caution
Results
The results were grouped as follows (a) Good when
the site of the naevus was invisible or needed at most
a faint dusting with powder to make it so (b) Moderate,
when there had been marked fading of only part of a
naevus, or definite but incomplete fading of the whole
naevus but only to such a degree that fairly heavy
cosmetic applications were still needed (c) Bad, when
there had been little or no change
The differentiation of degrees (6)' and JjeJ was by no
means^ easy parents are usually over-optiimstic, tending
to see improvement where i none has occurred , this was
confirmed in the few cases in which black and white '
or colour photographs taken at the begmmng of treat
ment were available for comparison '
The clinical details of the cases are sutnmanzed in
the Table Out of 44, the results were good, 20 ,
moderate, 12, and_bad, 12
Good Results — Analysis of the good results discloses
the very interesUng fact that 13 of the 20 cured had
naevi which, though classed as ‘ capillary ” or ' pprt
wine ’ when first seen, were raised at some stage of their
evolution It is suggested that at least these 13 recovered
spontaneously being in fact examples of small cavernous
naevi , and that the thorium X was not an appreciable
factor in their cure This hypothesis is supported by
the following facts , (1) There was no raised naevus in the
moderate or bad groups (2) Four of this group
improved only a little during the treatment, but after
wards disappeared completely (11, 11, 9, and 4 paint
mgs) (3) Ten of this group at one time raised and
subsequently cured had fewer than 25 paintings, and
five of these had IS or less This contrasts sharply
with the number of paintings given to the moderate and
bad groups, in which few of the patients had under 30
It would therefore seem that the degree of improvement
was almost inversely proportional to the amount of treat
ment, a fact showing ^sustained enthusiasm rather than
therapeutic efficacy (4) The known tendency of
cavernous naevi to spontaneous cure (see above) (5) All
these cases were cured by the age of 4i years, by which
time most cavernous naevi are known to resolve
There remained seven patients m the cured group
whose naevi were never noted as raised One of these
was of the suboccipital type, with a known tendency
to spontaneous cure The very httle treatment given
to four others (2, 9, 13, 15 applications) makes it prob
able that some of these, too, were cases of spontaneous
resolution Of these seven all except one (aged 40)
were cured by the age of 4 years
Moderate Results — Of the 12 paUents noted as
moderately improved all had flat naevi, the majority
of which were small or faint at the start of treatment
Their naevi have not regressed further since the discon
tinuance of treatment, but in every case it was thought
that treatment had been worth while
Bad Results — ^The outstanding , feature here Ts the
large number of applications which were given with
no useful improvement
Conclusions ^
It IS concluded from the above that, although many
of the good results were unconnected with the use of
thorium X, nevertheless the favourable results m the
moderately improved group were due to that substance
and It- IS thought that certain observations can be made
which will help in the management of similar cases
(1) Deep red capillary naevi are difficult to treat, whereas
the faint ones are easier (2) A capillary naevus which
is likely to undergo worth while improvement on
thorium X shows definite signs of it not later than the
twelfth painting a strong impression has been gained
that even in these faiourable cases no useful improve
ment is seen after a total of 30 to 35 appheaUons Case 5
Jas 20, 1951
HAEMANGIOMATOUS NAEVl AND THORIUM \
Ptrrm
^fn^ c*.i Jo'tKit.
121
W'as the only exception to this rule — a woman of ••0
who began to improve after 20 paintings and was \irtu
alls cured after 64 in fise and a half jears (3) It is
often stated that treatment with thorium X should be
started as early in infancj as possible It is probable
th I this idea has arisen because as m this senes a
pr> portion of children seen in the youngest age group
h t nacvi which arc going to heal spontaneously in
the senes gisen here nre included patients of 44 40
^ 13, and 10 who showed cure or improsemcnt while
s'- \tren whose treatment was b'gun early are no more
s I lent in the improved thin in the bad groups
Ancillary Treatments
VO patients who were considerably improved by
" um X derived further benefit from pm point cautcr-
ration of res dual teUngiectascs This can be done
without anaesthesia in an intelligent adult it is not suit
able for unanaesthetizcd children A loop-cautery must
never be used instead of a pin point, as it leaves
unsighllv pod lite scars
Carbon dioxide snow is difhcult to control is
unpleasant for the patient, and children treated by this
method seldom return for a second application It may
leave some atrophy and pigmentation if applied in ellcc
tivc amounts but occasional good results may be seen
in adults
The use of hcavv cosmetic applications is of the
greatest possible value when port wme stains persist
into adult life Judiciously applied they can in most
cases be relied on as an effective disguise and it is
unfortunate that at present they arc so expensive
Dctrits of Cotn
<8
Af St
Stirt of
Treatment
Set
Detcriiilon and Site
No ■rf
Faint
Ingt
Daratlon of
Treatne'*!
1 Time frem
1 Lilt Treat
i men! to Latt
1 Etamlnation
Rema ki
7 mthi
F
S'ishlly riited »*nall fofe*icad
Co^
40
^ftu ft
4 yn
3 yn
Some wtj VI "g a^J tr!i*'— <^aiU rrmiln ^
)
iO*ki
Itrg: left t
i6
S n£.S
6
S! c*f< atro'’\y S'tJ Np rca/r^-p
A
5
Ratted Iffi ide o«xtput
13
14
5
Mad received fxir ap''!>cit m. o' CO* tno»
Sh hi tc'a"'n*cta it and »nnkli-g remain
5
40 yn
r
Flat rore*ie3d and eyelid pmcnl at
64
yn
6 nthi
A few tclangt-^u ei retrain
0
? mth*
r
htrth
S tfihtly raited tmall now
It
1 yr
31 yr.
Fad'd a»ajr after irea mert had been ittr'-wd
12
4
r
Flat forehead and note
9
7 tntht
4
No trace re'*atn»
Sa.fut prewnt at end of trcatrvmt Pen fad d
13
8 a>Vs
Slightly railed rt(ht teg
4
4
31
a»ay q iite q « Vly No trace now
SI ght thtn in- of iVn and bafelx p-rce-llM#
teUng ectatit f ad d after »to'’-l ftreatmenl
SI ght sarieVlIng One of two telanr ctawt
14
9 mtht
TeUnfiieetatlc naenii flat forehead
2
1 rnth
4
17
l|)TI
r
Ratted note
24
2yn
3 rnih.
Thinrint oftkm and patch of aSient lanugo haJn
3
4 rotht
Nt
Rai ed eyelid
ts
7 rn hi
1 yr
MaJ rtoei ed 4 appl ^tioei of CO, mow
No trace of ta ••■ui
S
3 «
f
Kawl fa-e
21
17
i ypt
/I
3 ..
r
Slightly fa ted Iip
28
16
8 niht
5
i
SlightI) raiwvJ f>fehead
te
10
*1 yn
Faint Mje feck rtma nt
31
2\ >f»
r
I lit tmatl fa nt note
25
2>r«
21
Need a 1 itlr eo ering
3.
10
y
flatathmh later rated fa-^ 2letioni
29
H
ll
One If g-rt Oih r mo tH- slowly wIPo'Jl
3S
4 fpfhl
r
Flat n-vlffa ety faini rutcofneck
6
4
6 n!‘'i
f ftlser irtainvnt
Fal da^ajlfh
rv*gan tola rmly at end of trea m nt P n
)
9
i
I lat TO e
15
10 P" J»i
4
37
2 nihi
M
Sligh ly raiwd face
II
10
2 yn
ii a— 5-1 ed in tho-Jt f re n mtht
Fa d a«iT after a o-L-g ireatnent
3^
<• «
i
IJat d*er red tmal front of neck
13
1 n
IlotS c Vi— seired
4’
lOvVi
r
a"d fa nt on glaSelU
Rated n*ht Cheek
9
*nPi
10 tr ’■1
Fil d after tto~*5-girea •nent A few leorg ee
6
13 )n
M
X
Flat faw<
'xix - fir
20
Ij Tn
law. re~i n
Fo'ir ran later re'^-'t d by 1e ter I'-at I-ii*a
f
35 -
r
Pat fi'nj and rale*" ng*'t t.,w ceOk
23
21
11 yn
m** cnervnt tad n>t ma ained
«
44
r
and p — kr“t ttnee h rth
Flat left » wen k a -xeAreJ o*’r jinoe
*0
1 yra^J
Ffr r >ear» ti «t re’vrtcd lha tfra ■or-t
i
r
aged 3t
Pat p k left Sv^efa^
3
4 nthi
A-M-o
1 c\ h-d aVjn bjt o^"^Ji d *wt> ■•'a vi itill
r-ne-'l
S-c md ciyinefin pa'J) J en at am hnn u
IF
F
Ti 1 T* f-
9
34
I*)44
*i yn
i
J
f *k. '
c aue wat i. icaa g- aa n. cn
r rrJ
Le ! r 1 F r’sr ha la r o ma'kf* a-f
1<J
24 -
1 at fa e tna k d ic a -c«at'i »
34
*1
7 r~ ^‘t
C t ~a < y tcry g»3 ret- t a. rr tw cf p'- ::f
i ^
r
Flat fa-T Ixup — a 1 p 'k •'atcii 1 '
X7
5|
1
3 j
Ca— ef>
XI
4|
r
Flat fat e n e
FI. fa^ pa w.*“
X
M
1
* tstht
p ^n of t ra ew a ea
>3
* »*kt
. 1
11
“ r- 1 )
4 „
XT “J a » a f r*-t d n't
4'>
njn
F
r at Ti *1 r fa n It** ""h »*rTv^f a
15
J y. »
6 ~ )
La e-a”*^! gi •*-. a rs-ott p-o* O cf’y
4]
4r* h»
F )
and j" r - on to •n I \ “-.e :
tfe < j
Fla •'-a 3 i I . fa e and a-ck j
!
1
1
r“>-r*a 1 i- J -
S ”lc--- f t ^ P-H "V * t I fa- t- Ifat
1
*7*7
Tvl ^
•
Pat. J r" faze c-ti ar-
1
1
r-d /
ft
(
1
yn
1 y-
J — — : J"
0-^ a r sr- b a'nrs tj-ngo ta n
4 ^
pji t c tru V
Flj t— ,a < n
1
5 « ,
3 r->t »
r- •-»-» c»“ c‘‘-tki
V j^-a > O') c t'l
n
13
!
1 a t— J.1 f e fa d—
13
~x
yn
No c a-— a a
16
3
I
I awdT-r-- face hx. a" Irgt »
M n ^
1 y i
Pa - 11 . aca-y cii-1 ‘i
3 ^
r
Fla la fa e ^
j
4 ^
3-li
-'••C
P--.1. « ^3 3"^ {■« pa^t
< j-i
Pi w*r" r ^ f l» f f».e
ft
t ^ '
3 _
^ t- v n- Laia~-«t.rd
4
M -
V
F “x"' r— fa U'p- fa e
4
4 “ 1
nV^i "^^<*a-r-
'S
t
f 1 ’aTr faT
\t
* •• 1
\ J— ^ J J
X4
r
Pt fa c
3
!
— ^
' -3 c-arx 5 c -f t x-fzr:
5
I! -
r
Pi --S T“n fT cS— Vt a* ^n^Vx-
2 n
F*— a 'x ■* 37* ••Ts— CiZm^a - » C ‘KS
43
It ^
r
P»i ra *5 fa_e
-c
Per M
J n a»r“ a
Po* *7 1 f*— “"g
41
* — e-t
r
Pat wanp* 'a“*
|4
124 Jan 20, 1951
HAEMANGIOMATOUS NAEVI AND THORIUM X
BlUTTSa
Medical Journal
Summary
From the results of treating 44 haemangiomatous naevi
with thorium X it is concluded that (1) Some patients
denve useful benefit, but complete cure is not common
(2) The complete and spontaneous resolution of slightly
raised port wine ’ stains may erroneously be attributed
to thorium X (3) Contrary to previous belief; the age at
which treatment is begun does not affect the outcome
(4) There is seldom any point in continuing treatment
when improvement is not evident after 12 applications
and it IS rarely necessary or desirable to use more^han
30 applications in any one area (5) Atrophy or pigmenta-
tion does not occur if moderate numbers of treatments are
used
My thanks are due to Dr G IB Dowling for help m the
preparation of this paper and to Miss Pickering and the nursing
staff at St Thomas s Hospital tor their assistance and con
scienUous record keeping
' References
Airey F S (1944a) Proc R Soc Med 38 143
(1944b) Ibid 38 142
Corsi H (1943) Lancel 2 346
Ewmg J (1940) Neoplastic Diseases, p 254 Saunders
Philadelphia
Feeney P J (1944) Proc R Soc Med 38 142
(1947) Lancet 2 506
Forman L (1948) Brit J Derm 60 219
Jadassohn J (1932a) Handbuch der Haut und Geschlectskrank
'heiten vol 12, part 2 p 405 Springer, Berlin
(1932b) Ibid p 406
Lister W A (1938) Lancet I 1429
Lomholt S (1923) Acta radiol Slockh 2 437
(1936) Brit J Derm 48 567
Prosser Thomas E W (1939) St Thom Hosp Rep 4, 150
(1945) Brit 3 phys Med 8 72 ■
Roxburgh A C (1947) Common Skin Diseases, 8th ed p 55
Lewis London
Scholia W (1937) Derm Wschr lOS 1242
Silverman S (1946) Brit J Surg 33 307
Stelwagon H w (1902) Diseases ol the Skin p 644 Saunders
Philadelphia
The December issue of (he Practitioner contains an
mteresting expert article op the estimation of the prob
able number of casualties in the event of atomic bomb
explosion in Britain Flash burns should form only a small
fraction of the total British casualties because the weather is
seldom clear and the amount of haze will greatly cut down
the danger area below the two and a half mile radius found
in Japan, while high buildings and narrow streets will have
a valuable shielding effect The fire risk is thought to be
small apart from the danger of a fire storm like that
which caused 40 000 casualties in a single raid on Ham
burg The danger of exposure to gamma radiation is
summarized in three tables which show the percentage
mortalities at various doses as reported by the U S
Atomic Energy Commission the shielding value of con-
crete, and the probable casualties among a standard
population (one person per 1 000 sq ft or 27 900 per
sq mile) all in houses The first table ranges from 0%
mortality for 100 r to 100% after 700 r with an LD50
at 400 r At 2 000 ft over a mile from the explosion
centre of a Nagasaki type of bomb a 30 in thickness of
concrete will cut the radiation dose to 100 r and 32 in
to 25 r while at twice this distance from the centre the
required thicknesses are 16 and 21 in respectively Direct
blast injury is of little importance because the blast pres
sure necessary to produce serious injury is of the order of
50-100 lb /sq in which is only reached directly under the
bomb in an air burst at 2 000 ft The most important nsk
of all IS from debris which is likely to kill over much of
the area where gamma radiation is also lethal The final
estimate of the authors is a total of 31 100 killed and 29 500
mjured m a population of 43 per acre all inside houses
or of 14,300 killed and 10 500 injured if everyone were m
a reinforced bnck surface shelter
Medical Memoranda
Pemcilhn and Sulphamerazine in
Treatment of Typhoid Garners
Rumball and Moore (1949) cleared a chronic earner by
use of a combination of penicillin and sulphamerazine
They suggested that it was necessary to maintain the
blood sulphonamide level at over 10 mg per 100 ml
in order to obtain the full synergistic effect of penicillin
Following this report, we treated three typhoid earners
by this method
V
Case Reports '
Case I — A woman aged 63 had been in hospital 39 years
She had had typhoid fever m March 1915 From that
date until September, 1948, she had been kept on an enteric
caution card, but was not recognized as a carrier Follow
mg negative urine and stool exammations over a penod of
three weeks and a negative Vi agglutination, she was taken
off her enteric caution card Six months later on a rouUne
check she was found to be excreting Salmonella lyphi
(type F I) in both urine and faeces Penicillin 400000
units every three hours was given (total 24 000 000 units)
She also received sulphamerazine, 2 g eight hourly, to a
total dose of 38 g Blood sulphonamide levels were esti
mated on three occasions over the eight day treatment
penod On the second day the level was 51 mg
tree and 5 8 mg total' sulphonamide on the third day
5 8 mg free and 5 9 mg total and on the eighth day,
6 7 mg free and 7 mg total Penicillin estimations were
not carried out During the last 10 month? repeated
bacteriological examinations of both urine and faeces have
failed to produce a culture of Salm typhi
, Case 2 — A woman aged 64 Duration of present admis
Sion 26 years Thire is no record of this patient ever
having had typhoid fever, but she was exposed to an out
break in 1915 when she had been a patient during an earlier
admission There was also a further outbreak of typhoid
fever in 1943 On repeated bacteriological examinations of
excreta from all patients in the hospital one year previously
she was discovered to be excreting Salm typhi (type E, 1)
During the past 12 months she has been both a urinary and
a faecal carrier She was given a combined course ol
penicillin and sulphamerazine — 500 000 units of penicillin
administered intramuscularly three hourly, to a total o
30 000 000 units and at the same time 4 g of sulpha
merazine in the first eight hours, then 1 g, eight hourly
to a total of 25 g Eight days after the withdrawal of these
drugs both her urine and her stools became positive to
Sa/m typhi '
Case 3 — A woman aged 67 had been in this hospital 19
years Again there is no history of typhoid fever She was
however in the hospital during the minor epidemic of 1943
She has been excreting Salm typhi (type F D m both unne
and faeces over the past 10 months This patient wa
treated similarly as Case 2 with equally disappointing resu s
Comment
In Cases 2 and 3, which failed to respond to treat
ment, the blood sulphonamide level was maintaine
above 10 mg per 100 ml
The problem of a typhoid carrier in a mental hospital
IS one that must continually subject the authorities to a
certain amount of anxiety, and particularly that of the
carrier from the ambulatory or undetected chnical case
Ilf all cases of pyrexia of unknown origin occurring tor
three days or longer typhoid fever should be excluded
The history of these three patients shows that only one
had had a definite record of typhoid ^fever , the other
J^s 20 1951 MEDICAL MEMORANDA i;^
l
(WO were apparenllj undetected ambuhtorj ca>;cs md When ibe p'r c'e< d i'-- NSn e-w cnDii'r
were able to develop a chronic carrier state Despite
the variety of medical and surgical procedures that have
been advocated to rid the individual of his carrier con
ditin and despite the introduction of chloramphenicol
It V old appear that the treatment of the earner state
in tv hold fever still has to be solved
'' ' avc to IhanV: Dr J S McG epor the n dical sursmlcn
d or perir vv.on to publish this paper Wc ssould at o tike
to f CSV our thanks to the nursnp s aft conccrticd
ADM Douglas MB, D P H , D P M
Senior Prpslrar
D C Hunnsno AIMLT
Senior Labora orv Technaan
S ate Hospi al
IifTc-on Trent Notts
IlrtTpr T
I tl C A and Moore L G (19 9) dr/ilih ffejieel
iirrat 1 615
\ Case of Pethidine Sensitivity
I ollovving CISC IS of interest in \icv. of the intro
dL of mtra\cnous pethidine as an anacsthciic agent
to tjppicmcnl nitrous oxide Tnd ox>fcn (Mushin and
Rc -'ll BaVer, 1949)
Cast RrroPT
Tb patient a uoman aped 26 v\ciphed 7 st 6 lb
(47'' kp) and her pre*cpcnlivc blood pre^^surc was PO/
86 n Up Apart fron a historv and findings indicating
a pt nc ulcer for which aapoicm) was to be performed
she as in pood heslth There was no histoo <'f prcMous
illness
Prcmedication with morphine 1/6 pr (11 mp) and atro
pine I/ICKI pr (0 6^ mg) was piscn subcutancousl) and
one hour later a tc<l do<c of pallammc tncthiodid'‘
( fiaacdil ) 20 mg was pisen ntraNcncuslj into the left
arm after three minutes «hc complained of tiredness and
dip’opia As rcspintora difficultv did not occur a funber
60 mg was piscn followed immediatcl) h> 05 p of ihio
pemone The lungs were inflated cvcral (ernes wuh exsgen
and a «i7c 9 cuficd endolracbcal tube lubricated with
nup-rcatml** was pa«^ed b) direct lar>ngoscop> sm hoot
an\ di^’inilts Tlic tube was cnnncLted to a Waters
a«' nM> the cuf^ w-as infaled ard a mixtv rc of 1 litre
of exspen wjih 2 1 tres nitrous oxide was piscn m a
few cconJs ih* patient took a b e~th ard soon beg-n to
b calf c rcgularb
Jl^t be'o c tbc ppe^tion f arted 2' nc cf pethidine was
poen i'*trase'‘ousU jnlo tbc ngbt arm and the ssnrrc
strapped on The patient b'^came ap^o-ic ssubin sc^o^ds
and wns irfa -d rhs’Jn call) wi h a nitrous ox de-<jxsg-n
nix ire the bap bci-g enp icd (■» the air and refilled wnh
fresh g 2 *'*s esm n -u c o «o W'b'*n l^e a^do'rnal j-t
s i.-'n was nade it was no ic^d that tb-'c was sen li il-
bV*di''p a’-J t''e temp'^ral pu’s** ss^'ich was 1-0 a r-n*,
w^i c' P'S - so^u'^^ and fc'"*n cov’d no be fe’t at all No
b on 5 pTs' read "p co ’d b- e h* bv p-lpa
c b\ ax*s-L’ - n" «a b** pa •"! w^s p,t :n a ‘‘c^d
d t-n tvIl I was rc-«u'— 'g tb s' - Ve~ a gN^d col''
a-d as capi '*r\ rc^d i*"- v s o“ls sc-n I> re anf-d
-o r n--s^ rs s-c'e taken
Tb- op^*a’:on was c - s ^a i- p*'- I •*
d*^i*>-d as p^r^t -g C"-.. a-d a c'* c
9ti\c a-d pr-^s \ tca^T-d t c— was f-'^-d n fn p
jv. A ps’'‘apa s -d a**d
os>a d« r-d t ' 1 '' s s p- r-vtra ''•* 2^
r~ cs a' t''- p' d - Ivd p S'— a ssa ^ *• p-^s
o' *0 n— Hr wsy j — d-i -“d s^pjs
id— ** d a-d d ' d-^d M ■* r p •“»
; en — L .-d t' r - - r —
r-.dy a 12.’' a “w - lb » —
renosed and il - Lnps nfa’cd fisc or six tin-s s'l h pt rc
ox>gcn to de c rnne ih- d - h o' i’'acs’^'‘sn ssi ' in a few
-cenjs the pslicnl f'ok a deep b cath rnoscti 1 -r am*
and s Tinkled b-r fore’ -xd so the Tow o' mtrt s oxid-
w % resumed aril t''e sods Im- -ep’aeed b'*- continued to
brcxlh- artd <el Jed down in n few (1- <km i-a
sicn which h d b -n dr> b-gm to b’-ed bnsk!) the s>sto!ic
pressure hnsing ns^n to !0^ r^n Hg When tbc pc hidin-
sjnnge was rerrosed from the arm a skin sscal s%ns fund
running proximalls for nb''ul 4 in (10 cn ) it was cxnctU
supcrfi nl to d - course of the scin nnd rernned for a
funher two hours 1 --'nrc pndmlls d sippcnnng
At the end of the ope ation irachco bronchnl toilet wis
perfom-d and the endo ra-hcnl tulc rerrosed after b cath
ing pure oxsgen for !c»s than tsso mini cs the pxiicnt
regained full cons loiisncss anss ’•-ed q\ c' tons irtcllipcntlv
and corrphincd of h-adicbe She was returned to l^'d and
kept Imd down for six hours but ro furtber ill c'Tcc s sserc
seen The duration of ries besn w is on- and n half bourn
Apart fron slight nl domiml discomfort on the fi Ilownng
da> reco\cr> wns lincse-tful the patient ssas up cn the
third das and went hone 12 dnss after op-ration
As no account of n similar occurrcrcc could I c found In
the iPcraturc an attempt was made to investigate it ard
to d-sensiti/c the patient An infnd rmil injection of
0 I ml of p thidirc solution (1(V> mr in 2 ml ) produced
in the patient a skin weal 2 cm ir diam-tcr there being
no respons- to a control o' normal salin- Controls in
normal solunicers shossed that p-lhidinc in M^clf prodi ccs
a weal in all cases thouch it has been stated thit p-thi
dine artagonires histamnc (Gnib-r rt rl 1941) It has
also been learned that a sul cutaneous weal running along
the vein is not an bnusuat finding though not proioi s1>
d-scribed when rep-ated doses o' p'^thidine are given
throuch an ind selling intravenous n— die In ore con
sidcrablc series o' ca es it s as present quite often and In
Itself IS ..pparenti) of no sirnifi-ancc fU J Wo’fson—
pcrxo''a! communication)
Further inj ciions of 02 0’ ar'd 0 5 ml o' p- hidmc
solution copiaining 10 15 and 25 mp o' p-ihidin- rc pec
tisciv were given subaitancou'l) at hourlv intervals with
(he hop- of d-sTsiiirirg tie pa’i-nt One week Later a
sloss intravcpous inj-c inn of '0 mg of p-iludmc w is given
ard blood pressure readings sserc (a)cn apart fro-n slight
dros-sjpcss whi h p-rsis ed for an hour or two ro c"cct.s
were nppare-I
Although hvpotension rcspirato-x depre sion ^nd
bradvpnoca have b-en noted with larger dns« of
p-thidinc both in animals (Griibe- r/ cl 19-«1) and in
nv osn clinical exp— 'ir'-c no c e of t^is s-verit> has
xcl been repa ted in which the blood p cssu-c wa'
unrccc^dab'c fo- 20 minutes and in wb -h apno-a—
p-obabH p o’onged b\ ’’capno'^a m the late- < ages—
a*'d p-rfee* anaestbex a lasted fc one and a hv.lf hours
aftc- tnc rchtivelv small do - of 25 rr-* h '—ms ad as
al'e to give a p test do e of 10 rr- of p^h dm-
int-'vcnoLsh wlen s rr-l’'od of '•n-c- ^csia is lo be
LS-d
I .m t- * ** d to HD' rre Je'-'c-n f- pr— n.i -rs to
rr'> *1 1 : ce • f'T D II X\o i D x n «'d D- J A S—
c' t'- To -"d- - *t-d ^ Lr-J— '''f r
C'd tdx a"* o D L. J %Vr tt— ^ ctr"- i- a-jt't
V. fi ^ J mtt-'g ara
\ c - eal tod^rgx
D /ter ''B_ OB DA
i-i r P— j~* t- t''-* TV— A' —
Ic- -- i_-3 , ra»S c'lr- -
Prrne ee
Hr- r P^a'iC-vV* C ?',p- J
A. t-d P— vd' ” tr- L. /i T' ~
2 ^72
126 Jan 20, 1951
REVIEWS'
3unxR
Midical Jouuol
Reviews
t
HAY FEVER
Hay fever A Key to the Allergic Disorders By John
Freeman D M (Oxon) (Pp 321 71 figures £2 2s)
London William Heinemann Medical Books 1950
It IS a pleasure to review this book, for it is not only
full of first hand information but is in its way a work
of art^ It IS so clearly written that it can be easily
understood by any interested layman , moreover, it is
beautifully produced As the author states in the fore-
word, it IS an account of his stewardship to Leonard
Noon, his former colleague, and by implication to
Almroth Wright, his mentor '
This IS not a textbook but a record of Dr Freeman s
life s work and experience, which he recounts in a con-
versational style illuminated by a lively sense of humour
His chief concern is with hay fever, but he discusses
asthma almost equally fully Throughout the book there
IS a wealth of small clinical observations which add
greatly to its interest where else, for example, is noted
the frequency with which pdllen settles in the external '
auditory meatus, there to set up its intolerable itching
m sensitive patients 7 Case histones are abundantly
used , they are often amusing and always concise, so
that the appropriate point is made without the distrac-
tion of unnecessary information The humorous cap-
tions to the anecdotes enable them to be indexed m a
simple and effective way
Although Dr Freeman ts chiefly concerned with the
problem of sensitization as the basic cause of what he
prefers to call ‘ toxic idiopathies, he is no bigot He
takes care to point out that no single cause can entirely
account even for hay fever, which is generally regarded
as the most definite example of allergic pathology, and
that no one method of treatment is effective in every
case
The chapters on the effect of the emotions are par
ticularly clearly written and reveal great insight into
character and specially sympathetic understanding of
the feelings of children Although the author sometimes
tilts at psychiatrists it is evident that he attaches con
siderable importance to the mental state of the patient
The problem of infection is fully discussed, and his views
on how bacteria produce their effect in allergic dis-
orders are interesting and original Whether specific
sensitization to bacteria does in fact cause asthma is a
question he wisely leaves undecided but he gives sound
reasons for believing that bacterial toxins will enhance
the action of pollen and other sensitizing agents
In the chapter entitled Serous Leak ” he suggests
that acid fruits cause urticaria and other allergic symp-
toms by altering the concentration of lonizable calcium,
so that blood is made less viscous and serum leaks more
readily through the capillary walls There is little evi
dence to support this view
The author gnes full details of his methods of pre-
/panng extracts the technique of diagnostic skin reactions,
and desensitization One cannot help admiring the cour-
age of a doctor who teaches the patient to give him
self 54 mjections and like it but insists that no attempt
IS made to sterilize the skin beforehand It is reassuring
to know that no case of local or general sepsis has been
recorded from among more than a million injections
gi\en m this way The use of \accmes is also discussed
Dr Freeman dislikes medical jargon and is “ allergic '
m the sense of his third definition of this word to many
terms in common use, including “ allergy,’ atopy,’ and
immunity’ While admitting that these and similar
words are often used inaccurately or in different senses,
so jthat It IS imperative for an author to make clear just
what he means when he uses them, the reviewer is doubt
ful whether the invention of an entirely new set of terms
(toxic idiopathy, idiotoxin, phylactology, pathbphane) is
a satisfactory alternative
While, unable to agree with everything Dr Freeman
says, one is never in doubt 'about what he thinks or
about his reasons for thinking as he does What he says
IS the result of his experience, and he stmuilates the
reader This is a book that -any doctor will read with
pleasure and benefit, but it must be read by all who arc
interested in the study of allergy ~ ,
R S Bruce Pearson
SALTY WISDOM
The Four Pillars of Wisdom A Rational Approach to
a Healthy Education By Surgeon Vice Admiral Sir
Sheldon F Dudley KCB FRS (Pp 246 gs 6d)
London Walts and Co 1950
Looking at the short title on the dust-cover, one
wonders what may be the nature and the contents of
this book, a product obviously of relative leisure which
the distinguished! author has enjoyed after his retirement
from a turn of duties as strenuous, and as'heavy with a
tremendous responsibility to the nation and to the
worlds future, as the Royal Navy can ever have
laid upon any of its medical officers, for he was
Medical Director-General of the Royal Navy from 1941
to 1946 Is It a record, one wonders, of experience accu
mulated durmg earlier and, perhaps, more vanously
adventurous years in that great Service 7 The title page
adds the explanation , Admiral Dudley ^has been lookmg
back over a career which has, indeed, been unusually
varied in achievement and distinction — not many serving
naval surgeons have become Fellows of the Royal
Society by right of their own researches — and he has
been wondering whether the kind of formal education
which he received helped or hindered him in the things
that matter And in this discursive, uninhibited, anec
dotal, often amus|ng, and always interesting and stimu
lating book he records for us his own conclusions and
shows us how he has reached them ' It requires,” he
writes, “ a slightly more than average mtelhgence and
self discipline to accumulate medals and a post titular
alphabet — but no wisdom 1 So far as he has attained
the wisdom which it should be the first aim of education
to produce, he has had to do it by the hard way of
"largely unguided experience , and now he has found time
to give us his conclusions on what education should he
and might be
The ‘ Four Pillars of the title, the main components
of the structure of a true education should, he con
eludes be semantics (he was first impressed with the
importance of this by reading Ogden and Richards on
The Meaning of Meaning), psychology, statistics, and
logic These, he urges have a fundamental significance,
a prime necessity for a scientific education as distinct
from an education in science But Admiral Dudley is
not concerned with the detailed method of introducing
them into an educational syllabus) it is not his aim to
write a textbook of education The four pillars serve
him in the book as supports or pegs for a structure
Jan 20 1951
REVIEWS
BRiTtxa
Medical Jouwul
127
of personal musings, arguments '■and reminiscences m
which the ordinary reader, and the med'cal reader more
particularly, will find matter much more attractive for
the occupation of his hardly won leisure than any more
formal treatise would be likely to offer There is a
breezy freshness about the book which carries the reader
easily along and the chapter headings in spite of their
suggestion of an intellectual severity do not hinder the
author from any kind of digression which the natural
vagaries of his interest may start Under Psychology
there is a subsection on religion and we have Admiral
Dudley s views on this, as on all subjects, with a down
nght directness We gather that he is not in favour of
It in any orthodox form as a self confessed pre
judiced medical man wth a personal grudge against the
priesthood as a profession ’
Emphatically a book to be read and enjoyed, packed
full with the fruits of a salty wisdom
Henry Dale.
nANATOMY of the healtti service
The National Health Service By Roger Ormrod M A
B M B Ch (Oxon 1 and Hams Walker Annotations
to the National Health Service Acts 1946 and 1949
by John H Ellison M A (Cantab ) Reprinted from
Buttcrworths Annotated Legislation Service (Pp 241
£1 7s 6d plus Is Id postage I London Butlerworth
and Co (Publishers) Ltd 1950
The preface to this book states (hat it is designed to
provide a detailed account of the National Health
Service Acts of 1946 and 1949 and the principal statutory
mstruments which give effect to the Acts The authors
give a detailed^exposition of the Health Service, with the
texts of the Acts and of the principal statutory instru-
ments (up to June, 1930) They are both barristers, and
though one of them has also a medical qualification the
book IS written entirely from the legal point of Mew
They display the dry bones of the Service accurately on
the whole but without the flesh and blood with which
those who have to work the Serrice have clothed them
and without which it could not function Curiously
enough the only major blunder discovered is the defini
tion of a hospital (p 6 last two lines) where by careless
condensation of the words of the Act hospitals are made
to be convalescent homes instead of including them
It will be convenient no doubt for many people (but
chiefly for lawyers and administrators) to have the text
of the Acts and the principal statutory instruments in
one volume , but the flow of amending regulations and
rules necessitated by the growth of a large service will
make very frequent supp'ements or new editions neces
sary if the book is to retain its value as a work of
reference
F Gray
GYNAECOLOGY IN PRACTICE
Medical Gynecology "By Professor James C Janney
M D FACS Second edition (Pp 454 illustrated
£1 12s 6d) Philadelphia and London W B Saunders
Company 1950
This IS a happily arranged httle book designed for
general practitioners and m"dical students It presents
the practical and clinical approach to the subject Each
chapter is on a symptom^rather than a disease the sig
nificance of physical signs rather than pathology , medi
cal and physical methods of treatment rather than the
minutiae of surgical operations In one section the
author considers the principles and applications ^of
special tests and in another discusses at length the impor-
tant sociological problems associated with gynaecology
There are few textbooks which devote so much space
usefully to consideration of marital maladjustment and
Its prevention and treatment
Ideas of what a candidate should know of gynaeco
logy at the tune of final exammation, have changed
considerably in recent years and teaching is being
modified accordingly This book is a serious and satis
fying attempt to present the new outlook avoiding so
far as possible all that comes within the province of
the specialist It concentrates on the problems as they
present to the general practitioner and on the forms of -
treatment which fall wifhin his sphere /
T N A Jeffcoate.
BOOKS RECEIVED
Reideie is not precluded by notice here of books recently received
A Synopsis of Fevers and their Treatment Issued by
Virol Limned 9ih -cd (Pp 192 2s 6d ) London Virol
Limited 1950
Industrial and Safety Problems of Nuclear Technology Edited
by Professor M H Shsmos and Professor S G Roth (Pp 368
28s ) London Hamish Hanulion 1950
The Cerebral Cortex of Man By XV Penfield C M G M D
B Sc D Sc F R F R S and T Rasmussen M D (Pp 248
48s 6d ) London Macmillan 1950
Cell Growth and Cell Function By T O Caspersson M D
(Pp 185 28s ) London Chapman and Hall 1950
The National Health Service ^ Act sp^S Annotated
Supplement to sppS Edition By S R Speller LL B (Pp 285
27$ 6d) London H K Uwis 1951
A Textbook of Histology By Professor E ^V Cowdry 4lh
revised ed (Pp 640 60$ ) London Henry kimpton 1950
Whitaker s Almanack ipyt By J Whitaker F SA
(Pp 1 156 Complete ed 12s 6d shorter ed 7s 6d ) London
J Wbilaker 1950
An Addendum to King's and Some King s Men By H
Willoughby Lyle MD FRCS (Pp21I 30s) London
Geoffrey Cumberlege 1950
Atoms and Atomic Energy By R W Hallows TD MA
M I E E (Pp 196 10s M London Chapman and Hall
1950
Handbook of Diagnosis and Treatment of Venereal Diseases
By A E W McLachlan MB Ch B DPH FRSEd 4th ed
(Pp 368 17s 6d) Edinburgh E and S Livingstone 1951
Introduction to Diophthalniology By N A Slutterheim
M D (Pp 43 7s 6d ) London H K Lewis 1950
Principles of Internal Medicine Edited by T R Hamson
BA M D (Pp 1 590 90s ) London H h. Lewis 1950
Thomas fV Salmon Psychiatrist By E D Bond M D
(Pp 237 15s ) London Chapman and Hall 1950
Genetic Neurology Edited by P Weiss (Pp 239 $5 )
Chieago Universiiy of Chicago Press 1950
L ipilepsie Expenmentale By Professor G Morum
(Pp 139 No price) Pans Hermann 1950
La Stdnlite Uiialontaire By R Palmer '(Pp 493 1600
francs ) Pans Masson 1950
Hiriidurchblutiingsstorungen By Dr A Brobeil (Pp 264
M 45 ) Stuttgart Georg Thieme 1950 >
Allgeiiietne Pathologic By Professor F Buchner (Pn 528
M 32 80) Berhn Urban and Schwarzenberg 1950
128 Jan 20, 1951
THE SYMPATHETIC TRANSMITTER
BumsH
MnsiCAL JOUMOL
BRITISH MEDICAL lOURNAL
LONDON
SATURDAY JANUARY 20 1951
THE SYMPATHETIC TRANSRHITER^
The account of the hormones of the sympathetic ner-
vous system and the adrenal medulla in the opening
pages of this week’s Journal is of particular interest,
because it is written by Professor U S von Euler,
whose work m the penod 1944-6 did much to focus
attention on the substance noradrenaline In struc-
ture noradrenaline is similar to adrenaline except that
the mtrogen of the amine group which terminates the
side cham is not methylated, and in German it is
“N ohne radikal” Professor von Euler demon-
strated the presence and estimated the amount of
an adrenalme-like substance m many organs and
nervous tissues and showed that the compound had
the properties of noradrenahne The amounts were
greatest in sympathetic nerves thus the thoracic and
lumbar sympathetic chain and the splenic penartenal
nerves contamed as much as 30-100 ng per g He
inferred that noradrenaline iS the physiological trans-
mitter of adrenergic nerve action and supported this
inference by the observabon that after the nerves have
been cut and have degenerated noradrenahne almost
entirely disappeared from the organs supplied
The spleen has been found to contain, per gramme
of bssue about 25% of the amount of noradrenahne
m splemc nerves But the nerves withm the spleen
do not consbtute a quarter of the spleen bssue hence
It seems as if there must normally be a bansport of
noradrenahne down the nerves mto the spleen m
which It presumably exerts some funcbon hitherto un
descnbed The sympathebc bansmitter is not enbrely
noradrenahne but appears to be a mixture of nor-
adrenalme with a small amount (perhaps 5%) of
adrenaline There is considerable diEBculty in esbma-
bng mixtures of this kmd when the amounts avail-
able are small and it is nght to pay tnbute to the
pamstakmg work which has been done on this sub-
ject m the pharmacological department m Edmburgh
So far as is known at present there is little evidence
of excess of noradrenahne m the blood m clinical
conditions except when there is a tumour of the
adrenal medulla These tumours contam mainly and
sometimes almost enbrely noradrenalme and they
give nse to a large excrebon of this substance m the
urme — so much that the unne causes a nse of blood
pressure when it is injected without treatment into
an anaesthetized cat Therefore to diagnose an
adrenal medullary tumour it is better -to examme
the urme rather than the blood Von Euler and
Engel have shown that when a tumour is present the
normal excretion of 30 ^tg of L-«oradrenahne and of
10 jtg L adrenalme per day nses to more than 1 mg
Professor von Euler discusses many of the mterest
mg differences m the physiological properties of nor
adrenalme and adrenaline When given to man m
amount which causes a large nse of blood pressure i
noradrenalme does not cause the anxiety, discomfort,
and irritation which are caused by adrenalme More
over, Goldenberg and his colleagues have found that
there is an important difference m the effect of the
two substances on oxygen consumpbon in man
When infused mtravenously at the rate of 0 15 (ig
per kg of body weight per mmute, noradrenahne did
not affect oxygen consumpbon, whereas when adrena
Ime was infused m the same amount the oxygen con
sumpbon was mcreased by 25 % It is clear that there
are sbll important gaps to be filled m our knowledge ,
before a correct estimate can be formed of the physio
logical roles of the two substances When the physio
logy is clearer the part they play m pathological
condibons wiU also be more evident
TfflACETAZONE
The last five years have seen the mtensive study of
five chemotherapeubc remedies for the treatment of
tuberculous mfecbons Calciferol (vitamm Da) has
a curabve acbon only m tuberculous lesions of the
skin and its use m pulmonary tuberculosis seems
to be definitely contramdicated The sulphones have
proved disappomtmg m tuberculosis but^m the other
great infection caused by an acid-fast bacillus, leprosy
they are undoubtedly of very great value, especially
the parent substance 4 4 '-diammodiphenylsulphone
Sbeptomycm has been studied more mtensively than
any of the other drugs Its acbon, although most
remarkable m miliary and menmgibc infections, is
now known to be bactenostabc rather than bac
tencidal and some well-known disadvantages un
doubtedly attend its use Tubercle bacilli resistant to
sbeptomycm have been recovered m the USA m
France and m Great Bntam from patients who have
never themselves received the drug P A S (p ammo
salicylic acid) though less acbve than sbeptomycm
IS also less toxic and there is now growing evidence
to show that treatment with sbeptomycm and PAS
m combmabon retards the appearance of sbams resis
tant to sbeptomycm ^ Of the fifth anbtuberculous
Jan 20 1951
THIACETAZONE
Bwma
Moicax, JoinuuL
129
drug, thiacetazone much less is known, at any rate m
English speaking countnes
In 1946 Domagk and his colleagues- m Germany
reported that, among a number of thiosemicarba
zones p acetylammobenzaldehyde thiosemicarbazone
was the most active agamst tubercle bacdh in vitro
and also in experimental animals ’ Thiacetazone as
It IS now officially called has m the past suffered from
a surfeit of names In Germany it began as “ conte
ben ” or TBI-698 other proprietary names are “ ber
culon A ” “ seroden ” “ thioparamizone ” “ tebasid ”
and “ thiotebesme ” The action of thiacetazone on
tuberculous infection m mice was confirmed by
LevadiU,* who found it mfenor to streptomycm but
comparable m effect to PAS Experiments by
Behmsch and his colleagues® ' suggest that the sul
phur atom is essential for antituberculous activity
that compounds derived from aldehydes are more
effective than those obtamed from ketones and that
the aromatic aldehydes yield more potent compounds
than the aliphatic aldehydes ^The mtroduction of
substituents mto the aromatic rmg is also said to
increase activity Hoggarth and his colleagues’
examined a number of thiosemicarbazones and found
that though thiacetazone was effective m mouse m-
fections, yet p ethylsulphonylbenzaldehyde thiosemi
carbazone (termed by the Germans Tb III Be 1374
and m this country “berculon B”) was even more
effective and certainly surpassed PAS though not
streptomycm The relationship between the two sub
stances can be seen from the structural formulae
OI.CO NH CH =N NH CS NH,
Thiacetazone
QHsSO, C3I=NNHCSNHj
p-Ethylsulphonylbenzaldehyde thiosemicarbazone
Hamre and his co workers* examined nearly 100 thio-
semicarbazones and related compounds and found
that only eight were active agamst tuberculous infec-
tions m mice In order of potency the substituents of
3 thiosemicarbazone are ethylsulphonyl iso propyl
anuno ^acetamido dimethylammo, mtro, sulphamyl,
methoxybenzaldehyde Although only compounds
^ Medtcal Research Council investigation reported m the Bn(ish Mfdical
Journal J950 2 1073
* ^ It 3is
>48 39 1322
UfM. JJ
® Amer Rev Tubere 1950 6t I
1 ry r> — » o o > -Id®
Arch Otoi A r iy**v W
Proc MoyoClm 1950 25 160
‘oSchHtC, mfd Wrehr 19SQ 80 373
*1 Lanctt 1950 2, 286
active in vitro have an effect m the mouse there is no
correlation between the inhibitory activities m vivo
and in vitro ’
Thiacetazone can be given either by mouth or
parenterally It is not very soluble m water, but solu
tions can be made up m propylene glycol and some
acid amides A method of estimatmg the amount of
thiosemicarbazone m body fluids has been worked out
by Spinks ” The agreement between the amount
m the blood and the therapeutic effect suggests that
the thiosemicarbazones act directly rather than after
conversion m the body This is borne out by the fact
that thiacetazone, in addition to inhibiting the growth
of tubercle bacilh in vitro causes morphological
changes such as abnormal size granular dismtegra
tion and the appearance of delicate threads Bacilh
first of aU lose then capacity to take the Ziehl-Neelsen '
stain and finally the Gram stain It seems probable
that thiacetazone combmes with one of the blood pro
terns One way m which it is supenor to P A S is
that It IS not inactivated by p aminobenzoic acid
From 1947 onwards a very large number of cases of
^11 forms of tuberculosis have been treated m Ger
many “ ” Many of the treated cases, however, pro
vide httle or no real evidence of cure, smee there were
no controls and the period of observation was short.
In Germany the assessment of the value of a new drug
has been specially difficult because of widespread
malnutrition and a shortage of x ray films Hinshaw
and McDermott’* reported their observations after
visiting 10 of the larger German centres where the
drug has now been m use for four years The best
results have been seen m “ fresh exudate ” types of
pulmonary infection and m laryngeal and mtestmal
tuberculosis In some cases of tuberculous eye infec
Uon cures have been claimed “ In imhary infections
and in tuberculous menmgiUs results are far mfenor
to those obtained with streptomycm The dosage
used has been low— 25-50 mg daily for the first
week or two, with a gradual mcrease to 200-300 mg
daily if the patient can tolerate it Some workers pre
fer a maximum of 150 mg daily Treatment must
be continued for 6 to 12 months
While the therapeutic activity of thiacetazone still
awaits critical appraisal there is evidence to show that
It IS by no means non toxic Anorexia constipation
malaise dyspepsia palpitation, dizziness, pain in the
eyes, photophobia blurred vision and headache
often occur but vomiting is less common The
more severe reactions, occumng it is said m about
0 4% of cases, consist of toxic erythemata conjunct!
vitis, cerebral oedema, anaemia, and granulocyto
penia Fatal jaundice of hepatotoxic ongm has been
reported Oedema of the bram with severe fatty
degenerauon of the hver parenchyma was seen by
130 Jan 20, 1951 '
thiacetazone
Medical Jouexal
Heepe“ m three children who died after treatment
with thiacetazone A tendency to haemorrhage or
purpura is an early danger signal Other warning
signs are a fall-m the number of erythrocytes or white
cells a fall m blood sugar level and a nse m icterus
mdex During treatment the urine should be exam-
ined at frequent mtervals for cells casts, albumin
urobilinogen and sugar As the drug is a hver poison
the diet should be nch m protective foods Inter-
current infections hkely to throw an extra stram on
the hver parenchyma would be a contraindication to
treatment The possibility of bacilli developing resis-
tance agamst thiacetazone has not yet been fully
examined, but Auersbach and Schutz'^' believe that
thiacetazone-resistant strains can occur These are
then also resistant to other thiosemicarbazoncs In
order to dimmish the toxicity of thiacetazone attempts
have been made to combine it with other drugs The
combmation of sulphathiazole and thiacetazone was
highly toxic and has been abandoned Lepn and
Capalbi^“ showed that m expenmental ocular tuber-
culosis PAS and thiacetazone given together acted
synergistically More recently Karlson and his col
leagues” have suggested that streptomycin combined
with thiacetazone is more active than either drug
alone but ^Moeschlln and DemiraP" deny this and
find the combination of streptomycm and PAS
much more effective
It IS obvious that, although streptomycm is far
more active than thiacetazone. nevertheless the thio-
semicarbazones are a group of compounds with un-
doubted tuberculostatic properties Their true role
m human tuberculosis can be indicated only by care-
fully controlled mvestigations m which they are com-
pared with streptomycin and with PAS The possi-
bility of synergistic activity between these compounds
and thiacetazone also requucs much fuller study
In the meantime it may be noted that Ryne’* has
obtained encouragmg results m 10 cases of leprosy
after treatment for four months With doses of from
50 to 150 mg of thiacetazone daily- there was no
tendency to lepra fever, which is a danger with
sulphones In addition the mental depression and
slowing of cerebration so characteristic as effects of
sulphone therapy were absent
CONGENITAL MALFORMATIONS
Pliny said that Nature creates monsters for the pur
pose of astonishing us and amusing herself Up to
quite recent times it was widely believed that congenital
abnormalities were the result of impressions received
by the mother during pregnancy Empedocles, Plato
and Hippocrates all held that a severe fright dunng
pregnancy might leave its imprmt on the unborn foetus *
in n26 George I sent his chief surgeon to investigate
the story of Sarah Toft, of Godaiming, who was said
to have been delivered of 17 rabbits when five weeks
pregnant she was alarmed by a rabbit which suddenly
sprang up in front of her as she walked m a field
In recent years a great deal has been learned about
the aetiology of congenital anomalies Warkany,’
jvlurphy,’ and Kiskadden and his colleagues* have all
I’eviewed the subject in detail Warkany described the
experimental production of congenital deformities—
juch as cleft palate, horseshoe kidney, eye defects,
syndactyly, and other deformities of the skeleton— by i
exposing the pregnant animal to gross vitamin A, nbo
flavin, copper, or iodine deficiency, or to the noxious
pction of various poisons, such as selenium, hthium,
end X rays In a more recent paper Warkany and
Wilson^ reported that^gross vitamin-A deficiency can
eause cardiovascular anomalies, such as septal defect,
end anomalies of the aortic arch 'and pulmonary artery
Pypervitammosis A also causes abnormalities in develop-
ing bone, as Mellanby* has shown m a report which
■yenenJkij aipjeaneit m. *bjK, Vuw.'ial. In, aririifinn,, *hpxR. 's.
evidence that skeletal abnormalities can be induced in
developing chickens by the injection of insulm mto the
yolk of (he eggs ’ Murphy’ discussed the genetic and
statistical aspects of congenital deformities He states
that the chance that any. couple will have defective
offspring IS 1 in 200 The likelihood that a second mal
formed child will be born to parents that have had one
)S increased 20-25 fold The hazard of malformation
jnereases with the age of the mother, rising progressively
year by year after the mother has passed 30 The risk
of congenital deformities of the foetus being caused by
virus infections during pregnancy, particularly rubella,
js now well known Anomalies of placentation, such as
^ctopic pregnancy and placenta praevia, as a cause of
deformities is also recognized ^ _
I Recently Record and McKeown® have brought new
facts to light during a large-scale field study in Birming
Jiam \ They chose congenital deformities of the central
pervous system for study, partly because this group
would be expected to provide adequate numbers^ for
investigation, and partly because errors of diagnosis
were unlikely They recorded observations on the aetio
logy of 930 consecutive malformations of the nervous
system which were the cause of stillbirth or first year
death between 1940 and 1947 These constituted 059%
pf the total births in the city in that period The types
of malformation were hydrocephalus (150), spina bifida
(389), anencephaly (366), and other defects (25) In
^3% of the infants defects of other organs were also
present The homes of the mothers of these children,
and of those in a control group obtained by selecting
pvery 200th name in the registers of live and still births
for the same period, were visited by a team of investi '
gators It was found that the risk of a congenital
1 Gordon B L. Romance of Medltme 1945 Philadelphia
*/ 1 dvance tn Pedlitrlcs 1947 London vol 2 p I
^Canzrntl {f Maffo •natlnnr 1947 Philadelphia
• Int Abstr Su ? 1949 88 I
“ Pedlnt 1950 S 708
•P ithh Affdi al Jou nal 1950 2 535
3 Duraiswami P K ibid 1950 2 384
*Brit J roc Sfed 1949 3 183
•Ib,d 1950 4 2fi ^
*9 Ibid 1950 4 in the press
Jan 20, 1951
CONGENITAL MALFORMATIONS
Burma
Medical Journal
131
deformity was considerably greater for the, first preg
nancy and after the sixth There was no notable cor-
relation between the incidence of defects and social
circumstances, legitimacy, menstrual history spacmg of
births, or fertihty There was little evidence of the
importance of consanguinity The mcidence of mal-
formations of the central nervous system m all siblmgs
of a malformed foetus was 1 89%, and 2 77% m siblings
bom after a malformed one Thus the risk that
another malformed foetus might be born after the first
one was about six times greater ‘than the risk for the
general population (with an expected mcidence of
045%) The hkehhood of another malformation
seemed to be greater after the birth of a child
with spma bifida than after other deformities The
risk of recurrence of the same malformation was greater
than that of a different one though the latter risk
remained greater than the expected figure m the general
population It IS to be hoped that the continued acquisi-\
tion of knowledge about the aetiology of congenital
malformations will one day lead to their prevention
FOWL PEST
Whether or not any information applicable to the prob
lems of human epidemiology can be learned from the
study of Newcastle disease of fowls, the history of this
virus infection is interesting The present serious epi
demic m England has already necessitated the slaughter
of thousands of btrds and there is a danger that the
disease may become endemic as it hhs in America Eggs
would then be scarcer than ever and poultry more expen-
sive Newcastle disease, in its Asiatic form — which until
the present outbreak has been the only type encountered
In England — is an acute and highly infectious virus dis
ease of birds to which domestic fowls are particularly
susceptible The disease was first reported from the
Dutch East Indies in 1926 and in the same year T M
Doyle isolated the causative virus during an outbreak
which occurred at Newcastle From the Far East the
disease has spread predominantly westwards In 1928
It was reported from India (as Ranikhet disease), in 1929
from Japan, in 1930 from Ceylon and in 1931 from
Australia, where it was known as ‘ pseudo poultry
plague By 1937 it had reached East Africa and in
1940 outbreaks were occurring in Palestine and Syria
Soon It became widespread on the continent of Europe
In England the first outbreak was at Newcastle in
1926 there the epidemic spread rapidly through the
adjacent counties and then burnt itself out The next
was m 1933 at a large chicken farm at King s Langley
in Hertfordshire the entire stock of some 10 000 birds
was slaughtered and the epidemic was arrested England
then remained free from the disease until after the war
when poultry carcasses began again to be imported from
Europe In 1947 there were 2 222 localized outbreaks
It was the backyard flocks which suffered most — notably
in the earlier outbreaks, those around London and the
midland industrial towns where presumably imported
carcasses were common For two thirds of these early
outbreaks infected swill was either directly or indirectly
responsible The import of infected carcasses from the
Continent has continued, and not unnaturally so have
the outbreaks of Newcastle disease Bemg of the acute
Asiatic variety — the triad of peculiar respiratory symp
toms green diarrhoea, and neurological signs is charac
teristic — they have usually been easy to diagnose and,
consequently to stamp out In the laboratory a doubt
ful diagnosis can be confirmed either by the typical
post mortem findings of which severe intestinal ulcera
tion IS the most specific, by a reliable but technically
difficult haemagglutination inhibition test on the serum
or by isolation of the virus The serological test is
particularly valuable the litre starts to rise six days
after infection and has reached its maximum height by
the ninth day The test then remains positive certainly
for two years and possibly for life Thus a positive
result does not necessarily mean that a bird is suffering
from the disease at the time its blood is taken , it may
indicate an old attack, and this may be useful evidence
m tracing the origin of epidemicsx
It IS the American type of Newcastle disease which
now threatens the poultry industry in this country
Although this was first described in America m 1940,
and IS now thought to have existed there since 1935 the
condition was not recognized to be immunologically
identical with the Asiatic disease until 1944, when
Beach compared American material with sera and virus
received from this country Although the Amen
can disease is highly fatal to chicks and very mfec
tious, the symptoms are mild m the adult birds Out
breaks are not, therefore, so easily recognized The
present epidemic in England started last October on a
farm at Mildenhall on which swill from a neighbour-
ing U S Air Force station was used for feeding the
chickens Since then there have been 118 separate out
breaks of this low virulence disease, most of them m
East Anglia, but some have occurred as far away as
Lancashire and Kent Forty seven outbreaks have been
traced to birds which were at the National Poultrj
Show in December Nation wide extension of the dis
ease is thus a serious possibility Unfortunately the
chicks of the new hatching season are likely to fall easy
victims to the disease
The virus of Newcastle disease survives for only a few
days outside the fowls body unless it is frozen, but
while it IS living it remains highly infective, and can
readily be transmitted by swill and by coops clothes,
and other objects which have been in contact with
affected birds Its short life outside the body accounts
for the success of the policy of slaughtering, since
infected ground rapidly becomes safe and recurrences
m new stock from this source are practically unknown
Unfortunately the resistance of the virus to freezing
— It can survive for at least a year under normal
conditions of refrigeration — makes nonsense of any
attempts to control the import’ of the disease,
whether of the Asiatic or of the American vaneties,
except Jiy a total ban on foreign poultry — which mav
well be necessary It is known, for instance, that among
the food imported for American soldiers servmg in
132 Jan 20, 1951
FOWL PEST
BRmsH
MEDICAI, JOUKNAt
Bntain have been frozen fowls, and it is reasonable to
suppose that these may have been the cause of the
present outbreak The part played by wild birds in the
spread of the disease is not yet settled Outbreaks among
poultry of crofters living in the Outer Hebrides have
been traced to infected shag In America a starlmg
and in Scotland a gannet have been found to harbour
virus , and sea bird infection seems the most likely
explanation of an outbreak among chickens kept by
the Bass Rock light-house keeper Birds which have
had the disease naturally are thought to acquire a life-
long immunity
Newcastle disease is notifiable, and the Minister of
Agriculture has power to order the destruction of
infected stock and to control the movement of poultry
The difficulty in the present epidemic is one of recog
mtion, but serum tests are being widely used If the
policy of slaughter fails to stop the epidemic the only
other remedy is vaccination, and this cannot be expected
to be fully effective , its place is to moderate the disease
once It has become endemic Newcastle disease Is, of
course, primarily a disease of birds, but a severe con-
junctivitis has been reported in pluckers and laboratory
workers much exposed to the virus In these cases it is
possible to recover the virus from the discharges from
the eye but there are no serological changes and no
immunity develops Whether the conjunctivitis is due
to the virus or to the dusty atmosphere in which pluckers
work may still be debatable, but the evidence so far
would seem to favour a virus aetiology
RELAXATION IN ANXIETY STATES
The muscle relaxant mephenesin ( ‘ myanestn, ’ “ tol-
serol ) was introduced to clinicians in this country by
Berger and Bradley^ in 1947, and at the same tune
Mallinson- pointed out its potential advantages in anaes-
thetics These were then thought to be its non toxicity ,
Its rapid metabolism by the body so that all effect was
lost within five hours , the quick results of intravenous
injection , the satisfactory muscular relaxation which it
caused , and its lack of effect on the respiratory centre
, and on respiration Unlike curare, which has a some-
what similar chnical effect, it does not act on the neuro-
muscular junction but on the spinal cord Instead of
leading, like curare, to a state of psychological dis-
tress, It cau'ses, accordmg to Schlesinger, Drew, and
Wood,’ ‘ a pleasurable relaxation,’ drowsiness, and mild
euphoria Unfortunately later experience has not borne
out all these claims, notably that of non-toxicify ,
increased fragility of the erythrocytes, possibly result-
ing in dangerous anaemia * may be a consequence of
Its administration Anaesthetists have now practically
abandoned its use Another indication for the drug
nearly as important as the one it had m anaesthetics is
sUll under trial Mephenesin is absorbed from the
stomach and may be given by mouth in tablet or liquid
form It might therefore, be of value in the treatment
of neurological diseases causing spasticity such as
Parkmsons disease and disseminated sclerosis Unfor-
tunately while it does prove of some help both with
pyramidal and extra-pyramidal spasticity, so that it is
at the present bme being quite widely employed, it is so
rapidly destroyed in the body that m non toxic doses
and when given by mouth it does not cause any large
pr lasting effect in the severe cases which are in gfeatest
need of relief
Dixon and his colleagues are the authors of a recent
report which suggests that mephenesin may have a useful
application m psychiatry One of the commonest psy
chiatric symptoms — almost always present in anxiety
states and frequent also tn obsessional conditions,
involutional depression, and even schizophrenia — is a
state of tension, pamfully experienced as such subjec
lively, and showmg itself bodily in increased autonomic
tone, increased muscle tonus, tremor, and r/ther similar
symptoms Dixon and his collaborators selected a group
of such patients, who were physically healthy, actively
at work, and mainly between the ages of 20 and 50
Their complaints included dry mouth, gastro intestinal
disturbances, headache, and early fatigue They were
mostly found to have cold, sweating hands, dilated pupils
and vascular hypertension Mephenesin was given as a
chemical adjuvant to Jacobson’s well-known method of
treating tension stales by traming m relaxation , with its
help It was possible to show the patient what muscular
relaxation could be, so that he could know what to aim
at By taking the drug in a dose which varied between
0 75 and 4 0 g , the patient was provided with one period
of relaxation during the 24 hours, a period which did
not as a rule last longer than two to three hours The
authors obtained their best results with anxiety tension
states, however chronic, and 47 out of 50 patients treated
for this condition improved Rather less satisfactory
results were obtamed with the much smaller number of
patients in Vhom the tension arose on an obsessional
basis, or who were regarded as 'pre schizophrenic or
suffering from an involutional illness
Although little has been heard about the psychia
trie use of mephenesin in Britain, climcal expen
ments are being made at one or two centres, and the
provisional results conform with those of "the American
authors But pleasant relaxation and mild euphoria are
by no means always obtained, and some patients do'
not tolerate the drug well As is the case with all other
methods of treatment, the obsessional patient does not
react so well as patients suffering from other functional
conditions Nevertheless, the results which are obtained
are sufficiently interesting for further chnical trial to be
worth while Perhaps, as with other chemical discoveries,
a pathway has been opened which will lead to better
things Mephenesin is not a sedative in the ordinary
sense and belongs to a different family chenucally from
the other drugs used m both the neurological and the
psychiatric disorders in which it may be indicated If
mephenesm itself proves not -to be entirely satisfactory,
perhaps one of its derivatives will be found to have a
longer action and less toxic effect, and so come nearer
to requirements
V Zoned 1947 1 97
»IWd 1947 1 9S
‘Amrr J Med 1948 4 365
*Ko5itchcl, R J and Barnet G S / Amer med Aie 1950 143 22
‘Amer J med Sd 1950 220 23
Jan 20, 1951 /
TONStt-LECTOMY
Bwtxsh
Medical Jouwul
133
REFRESHER COURSE FOR GENERAL PRACTITIONERS
PROS AND CONS OF TONSILLECTOMY
t
BY
A H GALE, DM., DPH
Director of Medico! Postgraduate Studies and Lecturer in Epidemiology Vnnersity of Bristol
There are few subjects on which opinions are more
divided than on that of tonsillectomy The differences of
opinion are reflected in the bewildermg array of indi
cations and contraindications for operation given in
textboohs of otolaryngology and of paediatrics Gener-
ally speaking the indications given are of two kinds
those associated with purely local symptoms and signs
and those associated with gereral conditions particu
larly those in which Streptococcus pyogenes is believed
to play an important part Some authorities lay stress
on the local condition of the adenoids tonsils, and cer-
vical glands, whereas others say that the local condition
IS relatively unimportant and that the history of local
infection or of general disease is the important matter
in decidmg whether operation is necessary or not Some
authorities advise the removal of adenoids alone, par-
ticularly in young children, but it is doubtful whether,
in actual practice this is often done
Frequency of Tonsillectomy
There is evidence that these differences of opinion
have led to wide variations in practice For example,
in the public schools nhich took part m the report on
epidemics in schools* 60% of boys and 45% of girls
had had their tonsils removed before they reached
public school age, and in some schools the figure was
as high as 80% These figures are for pre war years,
but there is recent evidence to show that the rates are
not very different now On the other hand, we find
that in some of the great industnal cities less than 1%
of the children at primary and secondary schools have
their tonsils removed m a year which means allowing
for those who are operated on before they go to school,
that less than 20% of them will have had then: tonsils
out by the time ftey teach the age of 15 In some of
the south coast towns the operation rates approach those
found in children of the social class who go to public
schools Comprehensive reviews of tonsillectomy rates
m different parts of the country hate shown that
there can be no explanations of these great variations
other than differences of medical opmion and, possibly,
differences m the facilities atailable for performing
operations
When Should TonsiUectomies be Done*
The problem of tonsillectomy has recently become
even more complicated than it used to be because of
the mcreased prevalence of poliomyelitis Formerly it
was generally accepted that when the operation had
been decided on it was better to get it done in the
warmer weather, when streptococcal infections are at
their lowest ebb, but the fact that the prevalence of
poliomyehtis is highest in the summer and autumn has
complicated the issue and the problem is now not only
whether the operation should be done but when it should
be done
•Spec Rep Ser med Res Coim Land No 227 The report
covers the jears 1932-34 inclusive and summarizes the expenence
of 20 bo>s schools and 10 girls schools with an average popula
Uon of 10 270 boys (8 287 boarders) and 3 503 girls (3 061
boarders) A further report issued by the Medical Research
Council No 271 covers the years 1935-39
Docs Tonsillectomy do Any Good *
In what follows something will be said about statisti-
cal evidence because such evidence is objective and is
relevant to the consideration of the general indications
and contramdications of operation, but it must always
be remembered that all the statistical evidence in the
world, however carefully compiled, will not solve the
problem m the individual case Whether a child should
have his tonsils out, and when, is a clinical and not a
statistical problem
Evidence from Surveys
Several large scale surveys have been undertaken in
America and in this country m the attempt to decide
how far tonsillectomy achieves the objects for which it
IS done One of the best known of these is that of
Kaiser, who followed up 4,400 children , half of these
had had the operation and the other half, although
recommended for operation, had, for vanous reasons,
not been operated on Kaiser found that on the whole
the relatively short term follow-up, after three years re i
vealed greater advantages in the treated group than did
the long term follow-up, after fen years He points out
that this IS to be expected, smee older children are less
liable to suffer from infections of the upper respiratory
tract than are young children
Kaiser found that the advantage of the treated group
over the untreated group was most obvious when the
child had a history of frequent attacks of tonsilhtis As
a result of his survey he suggested the following as
being defimte indications for operation (1) mterference
with normal breathmg, snoring, etc , (2) difficulty m
swallowing (3) nasal or altered voice , (4) persistent
nasal discharge (5) impaired hearmg and otiUs media ,
(6) repeated attacks of tonsilhtis or qumsy , (7) enlarged
cervichl glands (8) sinus trouble , (9) growmg pams or
rheumatic fever , (10) pyelitis, nephritis , (11) unexplained
malnutrition and anorexia , and (12) retarded mental
development He considered that there was no advan-
tage to the treateo group m respect of lung diseases
It would probably be generally agreed now that some
of Kaiser s recommendations went beyond his evidence
and that many of his definite indications, particular!)
those involving general diseases — for example. Nos 9-12
— ^are at least very doubtful
In this country the approach to the problem has
been rather different, and attempts have been made to
compare the incidence of certam conditions which are
thought to have some association with tonsils and
adenoids in groups of children who have been operated
on and m groups who have not In the report on
epideimcs in schools, which was concerned for the most
part with children over 13 years of age, it was found
that there was virtually no difference in the attack rates
of nasopharyngeal infections, scarlet fever, rheumatism,
appendicitis, otitis media (with or without mastoiditis),
or pneumoma m the operated and unoperated groups
During the course of the mquiry 364 boys had their
tonsils removed, and in these cases the operaUon seemed
134 Jan 20, 1951
.TONSILLECTOMY
Bunsq
Medical Jouhmal
to reduce the amount of school time lost through illness
This section of the report ends with the words ‘ One
cannot avoid the conclusion that there is a tendency for
the operation to be performed as a routine prophylactic
ritual for no particular reason and with no particular
result ”
In a more recent but less comprehensive follow-up of
337 children operated upon at the Radcliffe Infirmary,
Oxford, in the years 1947 and 1948 it was found that
operation reduced liability to sore throats and to colds,
but the bther findings were more uncertain, although
there was a suggestion that the relatively small number
of children who had ear disease before operation were
improved after operation It should be noted that most
other authorities seem to be doubtful whether the fre
quency of colds is reduced by operation
In spite of the very large number of figures published
a really convincing statistical examination of the effects
of tonsillectomy has yet to be made It would not be at
all easy to plan such a survey, but the Oxford inquiry
gives an outhne of a method which might be adopted
Clinical Opinion '
As has been said above, the recommendations of those
whose views are entitled to respect, because of their wide
experience, differ considerably and are extremely dififi
cult to summarize There are, however, certain recom
mendationS which seem to be generally accepted *
1 Tonsils should very rarely be removed before the age
of 5 Adenoids should be removed at any age if they ate
causing nasal or Eustachian obstruction It must be reroem
bered that there are common causes of nasal obstruction
other than adenoids
2 The operation should not be performed on a child
who has never had symptoms whatever may be the appear-
ance of the tonsils Their appearance varies enormously m
the same child at different times
3 Tonsils should be removed on account of frequent
attacks of tonsiUitis with fever Ttue^totisilWis should be
distinguished from the transient sore throat which often
precedes the development of a cold in the head The exact
number of attacks in a year which should be regarded aS
significant is disputed — some would say two some three or
four It IS perhaps more important to consider the degree
of general disturbance — temperature and duration — rather
than the exact number of the attacks In this connexion it
IS misleading to think only of sore throats because a child
may have a quite severe degree of general disiurbance due
to tonsillitis without complaining much of sore throat
4 Tonsils should be removed at a suitable interval after
a quinsy
5 Tonsils should be removed in the very rare instances
when they are so large that they cause mechanical
obstruction
6 Tonsils should be removed in chronic diphthena carriers
when other treatment has failed
These ate the indications which would be generally
accepted and it remains to discuss the very difficult
subject of disputed indications
Disputed Indications for Tonsillectomy
Genernl Diseases
Tonsillectomy has at some time been recommended
for almost esery disease of children and for many con
ditions such as mental retardation or enuresis which can
hardly be called diseases Probably no one now believes
•The recommendations listed arc based largely on opinions
f isen et a discussion ai the Royal Soaety of Medicine (Proc R
oc hUd 1950 43 317)
that tonsillectomy has any influence on general dis
eases other than those which appear to have some asso
ciation with infection of the throat by Sn pyogenes,
and for practical purposes these may be jeduced to
juvenile rheumatism and nephritis There i^ little doubt
that when a first attack or a relapse of acute rheumatism
occurs It has often been preceded by an attack of tonsil
htis occurring about three weeks before, and the rela
tion between tonsillitis and nephritis is similar In these
cases It IS probably wise to apply the same criteria m
deciding the need for operation as those suggested above
for children m general It must be remembered, how
ever, that operation may have the same effect as an
attack of tonsillitis in precipitating an attack of
rheumatism or nephritis Operation should therefore
be done only when the disease has been quiescent for
some months, and under full cover of pemciUin
^ j
1
Enlniged Cervical Glands
This condition is so common in children and there are
so many causes for it that it is not a veTy_ useful guide
to decision Sometimes, however. Sir pyogenes seems
to leave th6 tonsils almost unscathed and to attack the
glands directly Admittedly it seems illogical to suggest
that when this process happens repeatedly it is an indi
cation for operation but I believe that it is This type
of occurrence is probably 'really an example of tonsillitis
without much ‘ sore throat ” ^
Risks of Operation
The operation has a small but quite definite mortality
No one knows exactly what it is because the total
number of operations performed in a year is not known,
,nor IS it possible to determine the exact number of
deaths properly attributable to the operation It seems
likely however, that about 80 deaths a year occur as
a direct result of the operation
The possibility of throat infections or even of septi
caemia following operation has heen mentioned above
With adequate precautions it should be possible to avoid
this risk ,
TonsiDccloiny and Polioniyditis
The possibility which has undoubtedly aroused the
greatest anxiety recently is that of an association between
operation and poliomyelitis As in the surveys on the
effects of operation, vast arrays of figures have been
amassed by both sides in this controversy Unfortunately
most of these figures are unconvincing
But a more important matter is that of the possible
association between tonsillectomy and poliomyelitis of
severe biilbar type Everyone has heard of the five chil
dren of one family in Akron Ohio, who had their tonsils
removed in August, 1941, and all developed bulbar polio
myelitis, of which three died The sixth and youngest
child, who was not operated upon, did not develop
poliomyelitis, although excreting poliomyelitis virus in
the faeces
In a nation wide survey of cases of poliomyelitis
treated in hospitals in this country m 1949, 16 cases of
poliomyelitis were reported as having followed within
one month of an operation for tonsillectomy Of these,
four died (two were brothers) of bulbar poliomyelitis,
four had bulbar signs and recovered, seven had the
spinal type of disease and recovered, and one had no
paralysis Admittedly the risk of a patients' develop-
ing bulbar pohomyehtis after tonsillectomy is a remote
Jan 20, 1951
TONSILLECTOMY
Bjuiuu
MOICaI. JOUHNAl.
135
one, but it is so tragic a possibility that few people would
knowingly allow their children to run it We know that
at certain times and in certain places the virus of polio
myeUtis is widely distributed among the population
and, when it is, tonsillectomies should be discontinued
altogether or at any rate confined to those cases m which
the operation is really a matter of urgency
Conclusion
The decision whether tonsillectomj is necessary or not
IS by no means an easy one and both the general prac-
titioner and the laryngologist have a contnbution to
make to it The general practitioner knows how often
the child has had tonsillitis and how ill he has been with
It, and the laryngologist is in the best position to evalu
ate symptoms of nasal and Eustachian obstruction and
to consider how far the child s symptoms may be due
to a chronic sinusitis Generally speaking it is better
to delay decision than to hurry it, and above all to avoid
operation on tonsils which have been recently inflamed
ORDER OF ST JOHN OF JERUSALEM
The London Gazette has announced the following promo ‘
tions in and appointments to the Venerable Order of the
Hospital of St John of Jerusalem
As Knights Drs Enk Hoerman and C Gardiner HiU As
Commanaers (Brothers) Colonel K B Fraser M B Drs E P
Scott R V S Cooper W B Fox J R Hanna CSC Prance
D J Nicol N S B Vmter and E M Humphery As Associate
Commander (Brother) Major S K Engineer O B E
F R C P Ed As Officers (Brothers) Drs S I A Laidlaw B
LaHaye C H Vernon B L Steele C E H Gaier H E
Thomas and L G Norman As Associate Officers (Brothers)
Lieutenant Colonel P M Petigara M B and Drs B B Rai and
K B M S Mahmood As Officer (Sister) Dr Ella P Hopgood
As Associate Officer (Sister) Dr Rose Baranov As Serxtng
Brothers Colonels R J M Home M B and J F O Grady
MB T D D L Majors W C Lowry M B E M D and R
Rutherford M P RA M C Drs M A Foulis J L du Preez
L F C Berlinguet L M Hanna J A Melanson G Racicot
J Robertson A Turner G S Mather J E S Hamilton A
Morrison T Staines Read N MacLeod C B Ball M B E
S G Nelson G J Duncan J R Thompson F F Heddle
E C Pope and I O Thorbura As Associate Sening Brother
Dr P K K E Raja As Serxing Sisters Drs Joan B
Landsman Margherila M Freeman Janet P Cooper .and Jane
M Adam '
In a recent issue of the Canadian Journal of Public Health
Sir James Stirling Ross draws attention to a passage in
Anstotle s Rhetoric (Book 1 Chapter 5) which discusses
happiness (eu^aip.ovta,eudaemonia) health (6Y(eia hygieia)
and well being in old age (euyTjpia, eugena) and says
of the last named in Sir James s rough translation
Eugena may be defined as slowness in the oncome of old
age with freedom from pain You cannot call a man happy
in his old age either if he ages quickly or if he ages slowly
but with pain Eugena comes from the virtues of the body
and from good fortune A man may be free from diseases
and enjo> physical strength and yet not be free from suffer
ing pain and without good fortune a man could not reach
to an old age There is also a certain power of long life
apart from strength and good health for many men arc
long li\ed without the Mrtues of the body But a high pre
cision in these matters is out of place in this discussion
Sir James suggests that the word geriatrics now in vogue
although without an> classical authonty should be dropped
in fa\our of the use of eucena which is also more
euphonious and expresses well the meaning of ageing
successfulh Geriatrics means the heahng of old age but
of course the doctors job is not to heal old age for it is no
disease but to protect it from going awr> "
Reports of Societies
VAGINAL DISCHARGE
At a meeting of the Devon and Exeter Medico Chirurgical
Society held on December 21 1950 Dr Margaret Hadley
Jackson gave an address on vaginal discharge
Dr Jackson said that some degree of discharge from the
vagina was normal though the character of the discharge
varied according to the age of the woman Thus micro
scopical examination permitted the recognition of infantile
mature (during the child beanng years) and post menopausal
(semle) types In the mature tjpe three distinct groups
could be distinguished by their charactenstic flora each of
which was commonly encountered and tended to be fairly
constant in any particular individual When confronted
with a case of vaginal discharge it was useful to attempt
to classify it as physiological due to hormonal imbalance
or pathological
Among infants and children whose vaginal mucosa was
thin the commonest cause of ■discharge was vagimtis either
traumatic from foreign bodies or masturbation or infective
due to the gonococcus or other organisms In the mature
woman other traumatic causes had to be borne in mind
such as nngs menstrual tampons or buned sutures after
penneal repair In addition one had to consider the possi
bility of allergic reactions to contraceptives of infestation
with tnchoraonas or yeasts (the latter particularly in preg
nancy and diabetes melhtus) of venereal disease of cervical
and utenne lesions and of fistulae into the bladder or
rectum In the post menopausal woman m whom the mucosa
had again become thm in addition to discharges due to
polyps or mahgnant disease one encountered an atrophic
vaginitis often charactenzed by a profuse and offensive dis
charge but with trichomonas and momha almost mvanably
absent
The history was of the first importance Was there imta
tion soreness dysuna or bleeding ’’ Had there been a venereal
contact’ The source of the discharge had to bj located
the unne tested and threadworms and piles excluded The
macroscopic appearance of the discharge was often charac
tensile To examine the discharge microscopically a speci
men should be collecled from the formces with a long
handled bakehte spoon and a' wet film made Elaborate
methods of illumination or staining were not essential in the
ma)onty of cases or unless venereal disease was suspected
Tnchomonal Infestation
Treatment must be appropnate to the cause that of tncho
monal and mondial infestations being sometimes tedious
Dr Jackson advocated ringing the changes on two or more
methods of treatment in cases of tnchomonal mfestation —
e g picragol powder acetarsol tablets or carbarsone
suppositones combined with douchmg with hypochlonte
solutions (as in vetennary practice) or with lactic acid — and
in cases where the mucosa was thin and most particularly
in the young the use of oeslrogens either locally or orally
Where the husband was also mfected with tnchomonas the
wife was constantly subject to reinfection however the
treatment of the male was extremely difficult
Out of a senes of 468 women attending the Whitechapel
Clinic 232 had been found to be mfested with tnchomonas
of these 102 also had gonorrhoea In a series of infertile
women attending the Exeter and Distnct Women s Welfare
Association clinic the incidence of tnchomonal mfestation
was 15% while in a birth-control senes at the same climc
It was only 5% This lent support to the view that chemical
contraceptives had a deterrent effect on tnchomonas
For the treatment of mondial infestation Dr Jackson
recommended alkaline douches and the use of a gentian-
violet-gljcenn and borax suppository for vaginitis m the
very young oestrogens by mouth or locally were un
doubtedly of value Non specific cervical discharges yielded
dramatically to treatment «i!h the electnc cautery together
with sulphonamides by mouth or pemcillm by mjeetion
136 Jan 20, 1951
CORRESPONDENCE
/
Burma
Medical Journal
Correspondence
Appendicitis in the Navy
Sir — I would like to ask Sir Cecil Wakeley in his capacity
of senior consultant surgeon to the Royal Navy, if his state
meat (December 16 1950, p 1352) ‘ There is no place for
expectant treatment applies to single handed ship doctors
who are not ‘ surgical specialists ’ Some thirty years ago
various comparative senes of appendicitis statistics could
show no definitely significant differences between immedi
ate operation and expectant treatment, as regards case
fitahty' in well looked after hospital cases under the best
surgical environment Therefore being no surgeon, I always
practised expectant treatment at sea and advised others in
like circumstances to do so I hasten to add that as Medical
Director General I never issued personally any orders on
surgical treatment though as M D G I did discontinue the
practice of congratulating those zealous young doctors who
removed appendices at sea with the assistance of the purser
and chief engineer always, for some obscure reason in a
raging gale I deprecate also the far too prevalent habit
(it may be a belief) of allowing patients to believe that only
an immediate operation can save their life if suffering from
appendicitis
The pomt 1 raise is important for, though in my long
expenence I recollect no serious disaster following either
immediate operation or a policy of ‘ wait and see ’ in the
treatment of appendicitis afloat there is no definite ruling in
the matter There is certainly a school of young naval
medical officers whose one desire is to remove appendices
afloat , but I believe but am not certain, that the expectant
treatment is far commoner in small ships with no adequate
surgical amenities It would be valuable therefore to have
Sir Ceal Wakeley s ruling on this subject He understands
(he conditions and knows the surgical capabilities of the
naval doctor better than I do In his great zeal for improv
mg naval surgery Sir Cecil may actually have some figures on
the treatment of appendicectomy at sea — I am etc,
Leamlmion Spa Sheldon F Dudley
Surgeon Vice-Admiral Ret
Appendicitis
Sir — I n the article by Sir Cecil Wakeley and Mr Peter
Childs (December 16 1950 p 1347) and in the subsequent
correspondence (January 6 p 36) it is clear that successful
treatment of the acute case depends more than anything else
(sulphonamides penicillin, etc ) on early diagnosis and early
appendicectomy with the minimum of trauma In the late
case particularly where there is a palpable appendix abscess
I agree with Mr McNeill Love that there is a place for
conservatism, provided the patient is under competent super
vision and is repeatedly and carefully exammed
It IS not enough to stand at the foot of the bed and study only
the hourly temperature and pulse record the abdomen should be
frequeutiy exammed Undue reliance on the temperature and
pulse rate as diagnosUc or even prognostic signs is a delusion
and a snare Most expenenced surgeons have removed gangren
ous and acutely obstructed appendices from patients who have
walked into hospital with a normal temperature and puke In
many cases especially m the obstrucuve type of acute appendicitis
a nsc of temperiture and puke rate follows rather than precedes
perforation of the appendix I beheve and have always taught
that many more carl> and accurate diagnoses with a consequent
drop m mortalu> would result if the temperature and puke rate
were completely ignored I have known many practitioners who
waned for a nse in pulse rate before diagnosing acute appendicitis
The ma;ont> of their cases had perforated before being adimtted
to hospital
The obstructed appendix situated in the pelvis (generally in the
astheme ty^pe of patient) is usually diagnosed late for the simple
reason that a rectal examination has not been made It is now
generally recognized that pain evoked in the appendix will be
situated m the umbilical region central because that is the early
embryonic position of the appendix and the position it occupied
when Its innervation was acquired The appendix has a bilateral
innervation whereas all bilateral organs have a unilateral innerva
lion therefore there should be no difficulty m diagnosing pain
producing disorders m the kidneys or ovanes Pam produced m
a kidney is always unilateral But m some cases of appendicitis
there is no central pain InUhe mild inflammatory type only
local tenderness and, later, local pain will be present, the reason
being that the threshold for intestinal pain is higher than that
for pain produced m the parietal pentoneum Again perfora
tion of an appendicular diverticulum will give nse to sudden acute
local pain as does perforation of a duodenal ulcer
Mr J A Ross s letter (January 6 p 36) deals with what
IS generally described as the ‘ lethal dose of castor oil
Surely it is not so much the action of the aperient which
precipitates disaster as the delay which ensues to see the
result Many thousands of appendices^have perforated in
patients who have had no castor oil In most if not in all
perforation wouljl b'e the inevitable result of the pathological
condition present if operation is deferred, and whether or pot
an aperient is administered
The decision regarding the site of the incision and the subse
quent steps of the operation should be made after due considera
tion of the situation of the appendix, its pathological condition
and the build of the patient (a point seldom considered) The
surgeon should remember that m the thm visceroptotic patient
adequate access is easy, that the mesenteries arc relatively long
and that the caecum and appendix will probably be situated low
in the abdomen or even in the pelvis In the stout sthenic indi
vidual the mesenteries are short, the caecum is probably sessile
and situated high m the iliac fossa In these latter cases a
high gridiron incision (or a Rutherford Monson mcision) will give
much better access and wilT result m a much easier operation,
for both surgeon and paUent, than a paramedian mcision
The surgeon who says, I always use this incision/ has
little imagination and has learned little from expenence, and
sooner or later will find himself in an avoidable difficulty
As Mr R Strang (January 6 p 36) wisely indicates, adequate
access (in all operations), and not the small pretty scar, is
the primary consideration if the best results are to be
ensured — I am, etc ,
Dundee F R Brown
Smallpox and Human Sacrifice
Sir — I am one of the medical officers of. health acutely
concerned with the movements of the original patient in
the Brighton outbreak of smallpox and should hke the
courtesy of your columns for making pubhc certain
observaiiODs
With the increasing frequency of air travel, we are apparently
unable to keep smallpox out of the country It is possible to
meet a man m the street, or train or bus who was on the
other side of the world only a few days before, and who is to
say that he is not carrying the Misease, modifled or otherwise ?
We fear the importation of smallpox because all tpo often some
body has to die before the importation is recognized And then
the pubhc goes into a flat spin demanding mass vaccination over
a Wide area to the detnment of the normal work of hospitals
general practitioners and health departments The tragedy is that
not one of these deaths is necessary but apparently we still roust
have OUT human sacrifices so that the general pubhc can go
unvaccinated It is of course no more than justice that the
sacrifices should be drawn from the great unvacemated Infant
vaccination confers some degree of protection for a great many
years Deaths from smallpox very seldom occur after successful
infant vaccination Similarly infant vacanation is fraught with
little danger from post vaccinal encephaUtis and protects agamst
the occurrence of this condition after secondary vaccination It
IS therefore gross negligence on the part of parents to omit to
have their children vaccinated m the first year of life If this
practice was universally carried out it would take only a few
years to build up the community s resistance so that death from
smallpox became impossible Fear of the disease would con
sequently depart In the meantime steps must be taken to
compel the reporting by anyone entenng the country of any iH
ness whatever which occurs within three weeks of entry
Similarly the onus of reportmg should he on any doctor
Jan 20, 1951
CORRESPONDENCE
Bxmsa
^b3)iCAL JOUWUL
137
encountenng such a case Failure on the part of the Government
to take immediate steps to enforce such a requirement would also
be gross neghgencc
There is nothing especially new in the views put forward
but It docs seem to take a long time for elementary facts to
penetrate the pubhc consciousness — 1 am etc
Eiirfn I C Monro
Treatment of Barbiturate Poisoning
Sir — In a recent letter (December 9 1950 p 1333) Dr H
Creditor suggests that amphetamine sulphate is the drug
of choice for acute barbiturate poisoning It is not made
clear on what clinical or experimental evidence this sugges
tion IS based In the more severe cases of acute barbiturate
poisoning the respiratory centre is markedly depressed and
this depression may rapidly prove fatal In animal studies
amphetamine sulphate has proved a feeble stimulant to the
respiratory centre and clinical observation has not suggested
any stimulant action in humans Picrotoxin on the other
hand has a powerful action m combating the respiratory
depression of acute barbiturate poisoning la my article
(October 21 1950 p 924) I stated that intravenous
amphetamine sulphate is a useful ancillary drug m the treat
ment of acute barbiturate poisoning In severe cases it
IS of little value m the early stages but may shorten the dura
Won of coma if given later I am not influenced by Riishede s
report of the treatment of 132 cases of barbiturate poisoning
with amphetamine (^Lancet December 16 1950 p 7S9) He
used the drug to supplement various general measures and
on account of a lower mortality in comparison with a
previous senes treated with nikethamide suggested that
amphetamine was a satisfactory cerebral and circulatory
stimulant His report makes scant reference to the import
ance of respiratory depression as the cause of early death m
these patients
The proper treatment of this condition must be based on
an understanding of the pharmacological and pathological
properties of the drugs concerned Barbiturate poisoning
may be rapidly fatal through respiratory depression or pro
longed coma may lead to fatal bronchopneumoma Deaths
from the latter are reduced by nursing care prophylactic
antibiotic therapy and attention to fluid balance and
amphetamine on account of its powerful awakening action
may shorten the duration of coma and hence reduce the
dangers involved The severe cases in which respiration is
slowed and the patient cyanosed call for urgent measures
to combat respiratory depression A mechanical respirator
or phrenic nerve stimulation may be used in the most desper
ate cases and picrotoxm is valuable as a stimulant of the
respiratory centre Amphetamine is useless under these
circumstances and its routine admimstration to alt cases
regardless of the cliiucal condiuon will lead only to
unnecessary loss of life — I am etc
London W C 1 J D N NaBARRO
Mcthjlene blue Test of Ice cream
Sir — It would be unfortunate if your annotation
(December 23 1950 p 1431) should give the impression tlrat
the methj lene blue lest forms a satisfactory basis for the
grading of ice cream The report [Mon Bull Mm Hlth
I9S0 9 231) nghtly points out the limitations of the 44 C
coliform test stating that only a few of the organisms isolated
were found to be faecal coliforms (48 faecal of 676 presump
rive) This reasoning applies with greater force to the
methvlene blue test taken alone since this is positive in the
presence of sufficient numbers not only of coliforms and
faecal streptococci but also of spore bearing aerobes
It IS possible during the course of manufacture to eliminate
all tvpcs of coliforms but the non pathogenic spore bearers
are frequently present m the raw matenals supplied to manu
faclurers and are unaffected by any form of heat treatment
which could be applied to ice-crcam. There is no justiflea
tion for your statement that the aerobe spore bearers are
a potential cause of food poisoning.
The 17 hour methylene blue test is open to even greater
objection It is argued that it indicates latent contamination
This IS totally misleading since spores of certain aerobes
isolated from commercial samples of ice cream when added
to the autoclaved ice cream as a medium and allowed to
stand for 17 hours at 20 C will cause failure of the test
within the four hours even though the number added be
only two viable spores Moreover the test is an unfair one
since there is no risk of anyone eating ice cream which has
been melted for 17 hours A test which can give a positive
result in the absence of intestinal organisms and a negative
result in tbeir presence can never be taken as the sole
standard of merit of any food product however convenient
it may be for the laboratory
The methylene blue test is at best a good screening test for
the degree of contamination of a sample but it can be no
substitution for the isolation and identification of the
organisms present — I am etc '
looeon w 13 W Howard Hughes
Health, Diet, Soil
Sir — I was very interested to read the account (December
2 1950 p 1272) of Sir Lionel Whitby s lecture Can Disease
be Prevented ’ Great advances have certainly been made
in the field of preventive medicine but one wonders why so
little attention has been paid to the factor of diet in disease
prevention Sir Robert McCamson gave conclusive proof
that food IS a very important factor m health and disease
and Sir Albert Howard went further and showed that not
only the food itself but the way in which it is grown (or in
other words the condition of the soil) could make all the
difference between health and disease m livestock By
increasing the fertility of his soil by banning artificial
fertilizers and usmg only compost made from animal and
vegetable wastes he was able to build up the health of his
animals to such an extent that they did not become ill He
says m one of his books that he has often seen his cattle
(in India) rubbing noses over the fence with cattle suffering
from foot and mouth disease — but his cattle never took the
infection He pointed out that tnbes such as the Hunza
who live on the whole foods grown on composted soil enjoy
great health and vigour and show considerable immunity to
disease
For some years now I have been advocating a whole food
diet With compost used m the kitchen garden when possible
and have found that all who adopt this improve in health
and vigour I used to suffer from frequent colds and chrome
catarrh but have found that these have just vanished since
following this way of feeding At the age of 45 I can work
long hours and never feel tired I would suggest that doctors
who are interested should try this way of life on themselves
and their families They will find an improvement m their
health withm a very short time — I am etc
Toobndsc Wdli Kent HECTOR W JORDAN
Congenital Deformities
Sir — 1 read with interest Mr G C Gordons letter
(December 30 1950 p 1495) I must admit I do not know
anything about his views on the causation of congenital
deformities in humans so I will await the publication of the
paper referred to in his letter with keen interest In the
meantime I would like to answer one or two points arising
from his letter
In the first place I have not made any suggestion in my paper
in the Journal (August 12 1950 p 384) that certain human
skeletal abnormalities may also be caused by msuhn though
according to Oakley and Peel (1949)' the incidence of congenital
abnorinalmes m children bora to diabetic molhers who were
'ptesomably treated with insulin dunng pregnancy was as high as
63% compared with a general incidence of 0 94% dunng the
same penod It is however not clear whether these congemta!
dcfortmties are caused by maternal hyperglycaemia and ketosis
due to diabetes meilitus or foetal hypoglycaerma which may be
cau5^ by the injections of msulm given to the mother dunng
pregnancy or by excessive secretion of insulin by the hyper
trophied islets of Langerhans of the foetus It will be mtefestmg
138 Jan 20, 1951
CORRESPONDENCE
BMtisa
Medical Joiddol
to know whether such a high incidence of congenital abnormal!
ties has been notieed in children born to mothers who suffer from
hypoglycaemia dunng pregnancy due to orgamc hyper
msulinism or other causes
Secondly according to Ingalls of the Harvard School of Public
Health, the implication of the valuable epidemiological observa
tions made in recent years regarding rubella mongohsm,’
encephalo ophthalmic dysplasia * oesophageal atresia, and tracheo
oesophageal fistula* is that the principles which govern the
disturbances of growth and differentiation in lower animals can
be applied also to human developmental arrests and malforma
tions Gregg* says I regard rubella and its sequelae as the
title of but one chapter m the full story of congemtal defects
many more chapters have yet to be written ’
Mall, after a lifetime mvestigation of the pathology of the
human embryo concluded that in the causation of human con
genital malformations ‘ faults m the environment are chiefly
to blame Since very httle is known of the detailed histology
of the early human embryo the histological examination of cases
of perverted growth and differentiation is mainly hnuted to those
abortions and stillborn infants which, not infrequently tend to
present vary mg degrees of post mortem degeneration before
accurate histological methods can be applied It is here that
experimental research can offer invaluable help and according to
Mall the pathological changes induced m human embryos by
environmental disturbances and those obtained experimentally
in animals are not analogous or sirmlar, but identical ’
I intend to send for publication a more detailed paper on
the experimental causation of congenital defects in chickens
bv synthalin sulphonamide compounds thallium salts
and 3 acetyl pyridine, and its significance in orthopaedic
surgery and I hope it will give further support to the above
mentioned observations In my preliminary paper published
m the Journal I could not give a review of the work done on
experimental teratogenesis, but I hope to include it m my
next paper — I am etc
Liverpool P K DuRAtSWAMI
,, REFSttSNCES
* Oaklev W and Peel J fI949) Quoted by F J Browne m Poir gfadi/ottf
Obstetrics and Gynaecolosy t950 p 405 iLondon Butterwortb andCo
•Ingalls T H (1947) Amer J Dis Child 74 147
* (1948) Pediatrics 1 315
i and Pnndle R A (1949) New Engl I Med 240 987
; Gregg N McA (1945) Med J Aust 1 313
«Mall,F P (1917) ,4mer J Anat 22 69
Death from Exsangumo-transfusion
Sir — T he letter of Drs P D Bedford and L G Lajtha
(January 6, p 38) in which a biochemical death after
exsanguine transfusion in a case of acute monocytic leuk
aemia is described deals with so important a subject that it
IS to be hoped that they will publish their observations in
detail
I think that the amount of blood they gave (19 6 litres) is the
largest amount that has ever been given at one session and it
would be interesting to know at what stage the first symptoms of
tetany developed The largest volume I have used at a session
was about 25 pmts (14 htres) 20 bemg ordmaiy blood from the
bank while five consisted of packed corpuscles At no time did
any signs of tetany manifest themselves
Another matter on which further information is essential is
why so large an amount was given at one time In the earliest
days of exsanguino transfusion for acute leukaemia it was
supposed that any benefit that arose was due to withdrawal of
noxious substances in leukaemic blood and simple replacement by
blood of better quahty The theory has undergone a good deal
of modification and it is now usual to suppose that exsangumo
transfusion acts in several ways It results m withdrawal of
enormous numbers of leukaemic cells and of much plasma which
may perhaps contam some noxious substance and it also supphes
more or less normal plasma m which there may be either a sub
stance required for the maturation of leukaemic cells or one
which inhibits their prohferation Certainly it is I think
accepted that any good results that ensue are not due to simple
replacement of blood or to lavage of the marrow by normal
blood If this be accepted there would seem to be every reason
for anticipating better results from repeated partial exsangumo
transfusions than from a single more or less complete one My
own experience and the more recent hterature of the subject
seem to support this view
Lest It be thought that I am an advocate of exsanguino
transfusion in the treatment of acute leukaerma 1 should hke
to say that in my opimon the operation whether at one
sitting or in repeated sessions should never be earned out
unless the patient or some responsible relation clearly under
stands that at the best a remission of a Very few months
may be obtained It is now clear that the procedure does
not cure acute leukaemia' and indeed the proportion of
cases in which remission occurs is small about 20% which
IS almost exactly the same proportion as m cases treated with
aminopterin or A C T H
It must alsOjbe remembered that repeated simple transfu
sions without concomitant exsanguination, are sometimes
followed by more or less complete remission For example
Andrd has recorded a case m which a remission following
this procedure (2 due to it) lasted for three years and seven
months the relapse that ensued was not influenced by
further transfusions
' I feel sure that Drs Bedford and Lajtha are acquainted
with Dreyfus s critical review of all the published cases of
remissions of acute leukaemia but those less versed in
haematological literature will find his reasoned discussion a
salutary antidote to undue optimism — 1 am etc
London W 1 A PiNEY
References
Andrf A (1950) Sang 21 833
Dreyfus B (1948) Jtey Hdmat 3 29
Metabolic Effects of Salicylate
Sir — The article of J B Cochran, R D Watson, and J
Reid (December 23 1950, p 1411) intensifies the confusion
created bv previous papers (Reid 1948 Reid el al 1950)
concerning the effects of salicylates on the body acid base
balance In this last communication the authors state that
salicylate produces a respiratory alkalosis, and then go on to
say
Large doses of salicylate lead to accumulation of the drug m
the plasma, displacement of equivalent amounts of bicarbonate
and a raised plasma pH As plasma pH depends on the
ratio HjCO, NaHCO, any reduciton in bicarbonate must be
accompanied by an equivalent reduction in the concentrations of
plasma I})CO, This may be achieved by mcreasing alveolar
volume which lowers alveolar CO^ concentrauon and therefore
plasma H^CO, The chmeal counterpart of this physiological
adjustment is the slow deep breathmg on salicylate admmistra
tion ’ (my itahcs)
Thus having admitted that salicylate produces a respiratory
alkalosis they ascribe the physiological adjustments to a
metabolic acidosis, repeating the mistake of Reid (1948)
Elsewhere (Rejd el al 1950) they agree that the primary
effect IS on the respiratory mechanism , and their published
data disprove the present suggestion that sahcylate displaces
eqmvalent amounts of bicarbonate
The actual disturbance of acid base balance produced by
salicylate was shown tovbe a respiratory alkalosis by Guest
and Rapoport (1942 1945a 1945b) and the probable reflex
origin of the hyperventilation was indicated by the observa
tions of Graham and Parker (1948) Carbon dioxide loss in
primary and subsequent adjustment of the plasma HCO,
level IS mainly dependent on renal mechanisms In healthy
subjects the kidney responds to an acute respiratory alkalosis
by the excretion of large amounts of sodium and potassium
bicarbonate (Stanbury and Thomson, 1951) a response which
if contmued unmodified could result in a considerable loss of
both extracellular and intracellular cation It is not known
whether salicylate in any way interferes with this renal
tubular response A clear understanding of the disordered
acid base balance m saheyhsm is essential for although
bicarbonate administration facilitates the excretion of
salicylate its indiscnmmate use could produce serious tetanic
convulsions (Rapoport and Guest i945a) Confusion is
however widespread and a recently published textbook of
medical treatment (Birch 1950) includes a nomogram pur
porting to define the dose of bicarbonate needed for correc
tion of the acidosis of acute saheyhsm
Lutwak Mann (1942) described many effects of salicylate
on cellular metabolism and also investigated the reducing
substances appearing in the unne dunng salicylate
Jan 20 1951
CORRESPONDENCE
BlUTTOI
139
administration It is certain that m addition to such priitnry
effects of salic>lale many disturbances of cellular chemistry
will result from the induced secondary alkalosis In this
respect it is interesting to recall that Haldane (1924) found a
reduced glucose tolerance and gi> cosuria in states of alkalosis
produced expenmentally by either voluntary hyperventilation
or bicarbonate ingestion It is thus conceivable that the
diabetic type of glucose tolerance curve found by Cochran
e! al in their patient on salicylate therapy was the result of
the respiratory alkalosis produced by the drug A state of
relative starvation resulting from anorexia might more
readily explain both the negative nitrogen balance and the
reduced glucose tolerance — 1 am etc
Manchester S W STANBURY
RrnjuscEs
Birch C A (1950) £mergencies in Medical Practice Edinburgh E and
S Livingstone Lid
Graham J D P and Parker \\ A (1948) Qua t J Med nj 17 153
Guest G M etat (1942) Amer J D i Child 64 200
Rapoport S and Roscoc C (1945) J dm Invest $4 770
HaJdane J B S Wiggleswortb \ B and \\ oodro^s C E (1924) Proc
To\ Soc B 95 15
Lutwak Mann C (1942) Blochem J 36 706
Rapoport S and Guest G M (1945) J dm In\est 24 759 ‘
Reid J (1948) Quart J Med ns 17 139
—— Watson R O atidSptoull D H (1950) lb\d IS I
Stanburj S W nndThomson A E (195!) Tobe published
Cusbing’s Syndrome and Aspirin
Sir — In their interesting paper (December 23 1950
p 1411)1 B Cochrin R D Watson and! Reid refer to
the occurrence of a reducing material in the urine It rna>
be that this material is a conjugate of acetylsabcyhc acid
4\nd glucuronic acid
The appearance of increased amounts of glucuronic aad m the
unne after salicjlate therapy \>as first reported by C Tollens*
and C Tollcns and Stem * Csonka* reported the conjugation
of bentoic acid \Mth glucuronic aad m pigs and later Quick
did a good deal of tsork on glucuronic aad conjugation mth
benzoic aad and its cten\atives including sabeybe acid iortho
hjdroJiybenzoic acid) m dogs and man Wagreich Abrams and
Harrow* estimated that 5% of benroic acid was conjugated as a
giucuronidc in humans while Kapp and Cobum* estunated that
2S% of sodium salicylate was excreted m humans m combination
with glucuronic aad These compounds have not been isolated
from human unne However it seems hkcly that sabcylic acid
glucuronider^is a diglucuronide in which there is an ether bnkage
between one molecule of glucuronic acid and the hydroxy! group
of sabeybe aad while the other molecule of glucuronic aad is
conjugated by an ester linkage with the carboxyl group of
salicylic aad In each case the aldehyde reducing group of
glucuronic acid is mvohed in the linkage and hence the glucu
ronides are primarily non reduang Howe\cr while the ether
linkage is alkali stable the ester linkage is very readily hydrolysed
by alkali and consequently ester glucuronides reduce Benedict s
solution directly In the case of acctylsaUcylic aad of course the
only possible linkage with glucuromc acid is an alkali labile ester
linkage Since reduction of Benedict s solution m these cases is
due to glucuronic aad naturally the phenomenon is not repro
duced by the addition of salicylates thcmsches to ibc unne
It IS of course obvious that although the exaction of
glucuronides of this t>pc may account for the appearance
of reducing matcnal in the unne it docs not exclude the
possibilitv of simultaneous true glycosuria — I am etc
Guttow John Paul
RtTERtNCrS
iTotlens C Hoi<pc-Se}l Z 1909 6 t 95
t sndSiem F ibid 1910 64 39
> CjonU FA/ bid Chem 19.4, 66 545
‘Quick A J Ibid 19.6 67 477 ibid 19 6 69 549 ibid 1932 85 189
ibid 1932 8$ 83 ibjd 1932 97 >.03
‘ W acreich H Vbrams A and Harrow B Proe Soc exo Slot JV Y
1940 45 46
•Kapp E. XL and Cobum A F / biot Chem 1942 14S 549
Lung Abscess and Sboii. Therapj
Sir —I hive read with interest vour annotation (December
16 1950 p 1377) discussing the relationship of lung abscess
to cleciro-convulsive thenipv During the last four jears
I have worked at a large mental hospital where extensive
use of ECT IS made m the treatment of depressive s>n
dromes Despite the fact that several thousand electro
shocks have been administered during this period I am
aware of only one case of lung abscess which might have
arisen from the shock therapy Even in this case a true
bill could not be returned against the ECT since the
patient had been both spoon and tube fed on innumerable
occasions dunng the three >ears before her death from
coronary thrombosis and lung abscess
Two other cases of lung abscess and one case of purulent
bronchopneumonia occurred during the four jear period
under discussion but two of the patients thus affected had
not at anj time been given ECT The third patient had
received a single shock at least seven months prior to the
appearance of the lung abscess An t ray picture taken
four months before the development of the abscess had
shown clear lung fields It may well be significant that
three of these four cases had been tube fed al various
times and in two the time interval between lube feeding
and the development of pulmonary sepsis vvas verv close
(days or weeks) Furthermore in one of these cases large
numbers of Bad coli were present in the sputum a fact
which suggests that a small quantity of milk may have
entered the trachea
It IS interesting to record that to the best of my know
ledge no case of lung abscess has occurred during the last
four years among patients attending the insulin shock
therapy clinic where glucose tube feeding is a routine
procedure
These facts suggest that in psychiatric practice a much
greater risk of lung abscess is involved m tube feedmg
debilitated and resistant patients milt, than m the
routine use of ECT It would seem wise however to
refrain from giving ECT in the presence of infected
gums and loose teeth
A study of the incidence of lung abscess m epileptics
might throw further light on the role of post convulsive
inspirauon in the aeuology of pulmonary sepsis —I am, etc
Thiouractl or Vertigo Epidcmica’
Sir— I vvas interested in Dr E Meulengracht s suggestion
(December 30 1950 p 1493) that the symptoms which
developed in a case under treatment with thiouracil and
which were attributed by me to the drug were m fact
caused by an attack of vertigo epidemica or neurolaby
nnthitis epidemica 1 cannot agree
Vehtigo epidemica is not so far as I know a common
complaint m this country and I myself am not familiar with
it under this name but if its symptoms are similar to those
that I have described they are those of labyrinthine disturb
ance and therefore common to any disease affecting that
organ whatever the cause In the case recorded I felt
justified m atinbuting the symptoms to thiouracil because
they canie on at a tune when other toxic manifestations -
usually appear during the course of treatment with this drug
Moreover they' receded when it was withdrawn Another
important feature is that nystagmus persisted and still
persists two years later This I imagine does not happen
in vertigo epidemica it certainly has not done so in those
cases of acute labyrinthitis unassociatcd with haemorrhage
and progressive deafness and presumably infective in origin
that I have observed — I am etc
Bnrhum C BaRRINCTON PrOWSE.
Sweat and Adrenal Function
Sir — In your annotation (September 16 1950 p 667) you
suggest that a test for use in the clmical laboratory for
determining the chlonde content of sweat might be useful
as certain observers believe that the concentration of salt m
the sweat bears a close relationship to the salt active steroid
production of the adrenal cortex For some time I have
been mvestigatmg the sweat excreted on the hands of
normal and rheumatoid anhntic patients many of whom
usually have clammy palms A detailed account will be
prepared for publication but meanwhile the following points
may be of interest
140 Jan 20, 1951
CORRESPONDENCE
' British
Mrdicai- Journal
1 The technique though simple is reliable, and the esti
mation being restricted to a small easily accessible area of
the skin IS suitable for routine clinical use
2 Separate estimations are made of total water, chloride
and urea '
3 It IS suggested that as the salt content may be supposed
to be related to the production of salt active steroids the
urea estimation may similarly be indicative of the produc
tion of sugar active steroids, which also control protein
catabolism — I am, etc
Hanosate A WOdDMANSBY
" Doctors for Boys’ Oubs
Sir — May I through your columns issue an appeal ’ The
London Federation of Boys Clubs is\bout to launch a
medical scheme This is m effect encouragement for regular
routine medical inspections of the members of the clubs It
has been found m practice that much good comes of these
examinations Some clubs already have such a practice in
operation but it is hoped to extend it widely That such a
scheme should work it is necessary for doctors to take part
voluntarily in the club life for a minimum of approximately
two hours in an evening every three weeks There are
many added ways in which such a doctor can be of great
help to the many clubs m London, and these together with
details of the scheme are contained m a short booklet which
will be sent to any doctor asking for one It is hoped that
' this letter may recruit those interested or willing to help
One detail will be mentioned here It is hoped to issue a
standard card for recording the results of such inspections and
u IS felt that in time these might be of great medical and statistical
value If the experience of such work (applying more to the
younger doctor) is added to this factor, it nwll be seen that the
ultimate good of the scheme is not entuely one sided Younger
practitioners on the house staffs of London hospitals are just as
welcome as the more permanent local pracutioners who may hve
near a particular club
It is wished to make two things abundantly clear Fust the
scheme is to be m no sense a sick parade but a senes of routine
medical inspections Second that the boys own doctors under
the N H S are never to be by passed or made redundant No
one expects these busy practitioners to carry out routine inspec
tions on apparently healthy adolescents and when any disorder is
detected they will always be approached
It IS entirely unnecessary to state what worth while bodies
the London Boys Clubs are especially m these days Any
doctor helping in the smallest way would give much pleasure
and might give invaluable help which would be most deeply
appreciated — 1 am etc
Frank Faikner
Hon Medical Adviser for the
l»ondOQ S E 1 London Federation of Boya Clubs
POINTS FROM LETTERS
■psychology in the D P M
Dr A FolfwSON (London N 15) wntes I have frequently
heard it expressed as an individual opinion by vanous consultant
psychiainsts that psychology as a subject for the D P M
(Diploma m Psychological Medicine) examination is academic to
an unnecessary degree A recently pubbshed book wntten by
a past examiner as a guide to the examination shows the academic
trend to a distressing degree The greater part of the volume
deals xMth the older systematic psychology of the philosophers
Inore usefully relegated to a history of psychology as m the
excellent Nolume by Professor Flugel May 1 mvite through
your columns collectne action by those who have reached senior
status to end this archaic situation ?
Dead Bodies in \\ater
Dr A Garme (Halifax) writes I have been on hobday this
New ^ ear near the banks of the Tay A farmer fnend called
and m the course of conversation happened to mention the came
of an old Dundee boatman and added Once when we were
rowing past the mouth of a tidal creek old Davy pointed to it
and said Monv a body Ive pu ed oot o there the men face
doon and the women face up
Obituary
Sir ARTHUR HALL, MD, FRCP
Sir Arthur Hall died at his home m Sheffield on Janu
ary 3 at the age of 84 For many years he was the
leader of the profession in Sheffiel^, not only by the
accident of seniority but much more because he was a
natural leader and commanded the complete confidence
of his colleagues
Arthur John Hall was educated at Rugby School,
Caius College Cambridge, and St Bartholomews Hos
pital, graduating M B , B Ch m 1889 He worked for
a year in general practice with his father in Sheffield
but after his appointment
as assistant demonstrator
m physiology m the old
medical school m Surrey
Street he decided to de
vote himself to hospital
and consulting work, and
)n 1890 was appointed to
the honorary staff of the
Sheffield Royal Hospital
At that time the medical
school m Sheffield had
been m existence for 60
years , but its life had been
precarious, and its future
was uncertain Hall threw
himself with enthusiasm
into teaching and organiz-
ation, and through good
days and bad — always an optimist — struggled on confi
dent that the school would one day come into its own
Jn 1897 the school was incorporated along with the
Firth College and Sheffield Technical School as the Shef
field University College At that time he was lecturer
m physiology and secretary of the clinical committee
and was very actively engaged m the negotiations which
culminated m the incorporation ^
Before long, overtures were begun with a view to
obtaming a university charter, and he planned, and very
largely directed, the transformation of a small local medi
cal school into a university department There were ups
and downs, and there were times when the whole scheme
of advance threatened to collapse , but he never lost
heart He not only planned but did much of the work
himself He occupied various teaching posts until some
one else could be found to do the work He resigned
the chair of physiology m 1898 in favour of Professor
C F Myers Ward In the same vear he became pro
fessor of pathology and resigned m 1905 m order that
Professor Louis Cobbett could be appointed He was
largely instrumental at this period in obtaining for the
growmg medical school generous benefactions, notably
the Arthur Jackson Chair of Anatomy in 1896, which
was fir^t occupied by Dr Addison now Lord Addison,
and the Favell Physiological Laboratory in 1897 A
charter was granted to the University of Sheffield m 1905,
which was opened ii) that year by King Edward VII
In 1928 the university, m recognition of Hall s services,
conferred on him an honorary doctorate of science
Hall was dean of the medical faculty from 1911 to
1916 and professor of medicine from 1916 until his
retirement m 1931 In that year a gift of over £500
subscribed by his colleagues and medical friends was
Jan 20, 1951
OBITUARY
Burmn
Medical Jouiuhal
141
handed over to the universitv to endow research In
1935 he received the honour of 1 nighthood, and in
1936 he was presented with his portrait which now
hangs in the councd room of the university
He was the architect of happy and cordial co opera-
tion between the various Sheffield hospitals and it was
at his instigation that a club was formed composed of
the honorary staffs of all the voluntary hospitals It is
now known as the Arthur Hall Club As a teacher he
gained the respect and admiration of his students and
by his example impressed upon them the dignity and
importance of their calling It was not for nothing that
successive generations of students spoke of him affec-
tionately among themselves as Lord Arthur He was
always concerned for the welfare of his younger col
leagues, helped them in their difficulties encouraged
them in their professional work, and looked after their
interests when abroad on war service His own services
and distmctions were not limited to his native city In
1904 he was elected a Fellow of the Royal College of
Physicians and subsequently served the college as exam
iner, councillor, Lumleian lecturer (1923) and senior
censor (an exceptional honour fora provincial physician)
He did work of great national importance on the Radium
Commission, as a member of the Industrial Health Re
search Board, and as chairman of a committee of the
Medical Research Council on pulmonary dust diseases
In 1924 the year he was president of the Section of
Medicme at the Annual Meeting of the B M A he was
also made president of the Yorkshire Branch Another
honour which fell to him was the presidency of the
Association of Physicians of Great Britain and Ireland
in 1931 He was an external examiner for many univer
sities mcluding Oxford, Cambridge, London, Man
Chester Glasgow, Leeds, Birmingham, and Bristol In
addition to all these activities he found time to do
original work, and his most notable contnbution to
medical knowledge was his work on encephalitis lethar
gica His observations on this disease were made mainly
in Sheffield during and after the first world war and arc
embodied in what is now a standard work on the subject
He was a man of very wide culture His chief interest
outside medicine was probably music He was a very
able musician and it is said that if he had chosen music
as a profession he would have achieved great heights
but early in his career he reluctantly came to the con
elusion that there was a certain incompatibdity between
the concert platform and the work of a consulting physi
cian He had a fine sense of humour but it was never
exercised at the expense of others with it he embel
hshed his lectures and speeches which were always
models of what lectures and speeches should be
Sir Arthur Hall is survived by a son and a daughter
His wife, whom he mamed in 1900, died m 1945 We
have lost a great figure in medicine, probablj greater
than we realize, and all those who knew him have lost
a generous and charming friend — A G Y
CHARLES ERNEST WEST FR.CS
Mr C E West consulting aural surgeon to SL Bartholo
mew s Hospital, died at his home in Budleigh Salterton
on January 1 aged 77
Charles Ernest West was educated at Merchant
Tavlors School Crosbv and Balliol College Oxford
to which he obtained a classical scholarship He gamed
a first in classics and then became interested m science
cspcciallv chemistrv and under the tutorship of Sir John
Conrov who had founded the school of chemistrv at
Balliol, he obtained another first in natural science He
now made up his mind to go in for medicine, and,
remaining at Oxford read anatomy under Arthur
Thomson and physiology with Professor Burden
Sanderson He left Balliol in 1897 entering St Bar
tholomews Hospital with the senior open scholarship
in science, and next year passed the primary fellowship
examination (R C S ) He qualified MRCS, LRCP
in 1900 and also graduated B M His future career was
assured when he was awarded the Brackenbury surgical
scholarship and Sir George Burrows prize and was
elected house surgeon to Mr Alfred Willett then senior
surgeon of the hospital In 1902 he was admitted
F R C S and was made a junior demonstrator of
anatomy, regarded in those days as a probable step
to candidature for some future vacancy on the staff
Sir Holburt Waring was head of the anatomical depart
ment and it was no doubt through his initiative that
West was encouraged quite early to start specializing
in diseases of the ear, rather than follow the course of
genera! surgery
This was the beginning of a period of renaissance at
St Bartholomews, which became evident with the re
building of the out patient department and improve
ments in the special departments West was appointed
chief assistant to Mr A E Cumberbatch, who for 20
years had been aural surgeon and he held this appoint-
ment for five years before being elected aural surgeon
on Mr Cumberbatch s retirement 3Vhethcr in out
patients m the wards, or m the dissecting rooms and
pathological laboratory, he worked unceasingly with
the guidance of Sir Frederick Andrevves and Lord
Horder to carry out researches in bacteriology of
diseases of the ear to which hitherto little attention
had been given He published several pafiers on his
personal observations, in the hospital reports and else
where Mr Cumberbatch, proud of such an enterpris
ing and enthusiastic assistant, encouraged him in every
way to gain experience and practice in the surgery of
the car He developed skill as an outstanding operator,
and as he admitted, he received inspiration from the
works of Sir Charles Ballance and Sir William Macewen
Before long practically all patients admitted to the hos
pital with mtracramal infections, if due to ear disease,
were referred to the aural department for treatment
He was the new author of Diseases of the Ear in
Gask’s edition of Walshams Surgery and was co
author, with Mr Sidney Scott, of a book enbtled Opera
Uons of Aural Surgery now out of print, written
chiefly for house surgeons and junior specialists In
the Section of Otology of the Royal Society of Medicine
he played an active part Among many contributions
was a joint paper, written from personal experience on
the surgery of the labyrinth which was the first of its
kind in this country
West had built up a large and successful hospital and
private practice and he was under 50 when he decided
to retire and leave London He was a brilliant conver
sationalist and writer and a connoisseur of good things
He enjoyed golf and badminton, but more than in these
was his delight in sailing and motor boating, especially
during the earlier years of his retirement to Flushing
near Falmouth During the second world war he lived
at Sturminster Newton, m Dorset where he became the
medical officer of a local Home Guard battalion In
the first world war he had held a Temtonal commission
in the R.AMC, working at the Camberwell Hospital
where Sir D Arcy Power was commandant
142 Jan 20, 1951
OBITUARY
Britisb
Medical Jourjial
After 1945 he moved to South Devon, keeping up his
interest in gardening and the countryside Though his
health was not too good, he could still enjoy motoring
and twice visited Denmark He also retained his interest
in music, hterature, and in reviewing books — even some
of the queerest His writings for the Press were usually
anonvmous and nearly always on non professional sub
jects West had a keen sense of humour and was an
excellent sjieaker His first wife died some years after
their marriage in 1908 His second wife was Miss Kath
leen McCrossan who was his constant companion to
the end He had no children — S R S
EBB v/rites Charles Ernest West was a leading
member of the team of ear and throat surgeons who in
the period around the first world war made Bart s the
greatest school for the two specialties combined that
existed in the kingdom I gave anaesthetics for him
before the war and was his houie surgeon and then
clinical assistant after, and I loved him as did all those
who were responsible to him for their work He had
a wonderful loyalty to his team If a man was doing
his best West would take the blame for anything that
went wrong and he would back his junior against any-
one on earth
He was a great teacher, able to make ear surgery
appear simple He had a very powerful mind and a
vigorous body, and his teaching was always phrased in
striking and memorable English I have watched sur-
geons in several countries, but I have never seen his
equal in technical skill His courage was outstanding
If operation was a patients only hope West would
operate no matter how slender the hope might be His
speed cquld be astonishing when it was needed I have
seen him do a good radical mastoid and open a cerebellar
abscess in an unconscious patient in 13 minutes
He retired in 1921 at the age of 48 and went to Fal
mouth There he used to work a six ton cutter off the
rocky coast single handed Eighteen months later he
- tore everv muscle off a tendo Achillis jumping for a
shot at badminton This put an end to his sailing, and
he took to what he called water motoring , but he never
complained ' He retained his vigour and interest in life
to the end and was a most amusing correspondent All
mv working life I have tried to follow in his foot-
steps when dealing with a surgical problem or with my
juniors He was a man I shall not look upon
his like again ~
Sir LEONARD PARSONS, MD, FRCP
FRCOG FRS
Mr Seymour Barling writes To have had Leonard
Parsons as a friend for over 50 years was a rich expen
ence in life Not a few of those who attended his
memorial service in the Birmingham pro cathedral
and who had been his fellow students and colleagues
throughout a long life felt a loss greater than the man
himself as if some spirit that sustained him had been
lost to them and left them the poorer for its going
Those of us who knew him in his earliest years as a
medical student realized that he brought with him into
the school those salient qualities of mind and character
that were to stand him in good stead throughout his
life These basic qualities came with him from his
simple home background with a strong religious disci
pline Thev remained with him essentially unchanged
as his guide and inspiration for his life s work
Rather shy and abrupt in manner as a young man,,
and appeanng at first-to stand a httle aloof, he did not
make fnends easily and even from his many friends
few became his intimates but these remained so for
life and in them he had complete trust and confidence.
Outside this small circle his normal academic life was-
carried on with zest in his work and in his athletic activi-
ties, the two most important of which were rugby foot
ball, in which he played for the Aston Old Edvvardians,.
and cross country runmng, in which he was an expert
and well known exponent, attending many meetings in
Birmingham and the Midlands By the time he was a
prosector in anatomy in his third academic year it was
obvious that he was becormng an outstanding student
forming one of a group of men who at that time
emerged from the Birmingham medical school and
who all m various degrees became distinguished in
their professional life
The period he spent at the Children s Hospital, Great
Ormond Street, was undoubtedly a, turning-point m his
life Before going to London he had been house
physician to Dr Arthur Foxwell at the Queen s Hospi-
tal, Birmingham and Parsons often acknowledged the
debt which he owed to him and to Dr James RusselL
of Birmingham, for the inspiration and grounding they
gave him in clinical medicine At this time it would
seem that his interests were wholly in general medicine,
and It wasjvnly after his work at Great Ormond Street,
where he came under Stills influence, that his lifelong
interest m diseases of childhood emerged About this
time he undertook his first serious research, in associa
tion with Tyrell Grey, on the fundamental changes
underlying the condition of shock, on which the Arris,
and Gale Lecture was based He was associated with
Still in some of the earliest cases of congenital pyloric
stenosis to be treated successfully, and thts led to his-
interest m problems of child nutrition, which expanded
later mto his studies and researches in coeliac disease
In lookmg back it is interesting to study some of
the milestones which started him along the road which
he trod so successfully, and I have a feeling that the-
child as a patient made a deeper appeal to him as a
subject for clinical study than the more sophisticated
adult patient and he was happy mdeed to find his life s
work amongst those whose interests made such a strong
appeal to him The keynote to his character was
simplicity and sincerity, and he did not allow himself
to be distracted from his mam path by the fret of
modem life In many ways he possessed the great
quahUes of some of the most zealous and distinguished
of the Victorians who accomplished their Iifes work
by an immense capacity for hard work and a burning
zeal for achievement To this he added all the tech
mque of modern research, gradually teaching himself
the art of writing and expounding fluently that others
might be inspired to carry on the work which he found
so satisfying
A D writes May I add a brief but very personal
tnbute to the memory of Leonard Parsons As an
old friend of his I have the most grateful recollections
of his manv kindnesses to me and to my patients, his
generosity to the latter being always unlimited I well
remember one occasion on which he was attending me
during a short illness On his first visit seeing that I
was worried about my (general) practice during m>
enforced absence from work he immediatelv offered
to carrj on part of the practice for me This when
Jan 20, 1951
OBITUARY
BRiiroi
VtEDlCAt JOUXJvO,
143
one considers his preoccupation svith a busy consultant
practice shows what manner of man he was, and for
that reason I am very ghd to put it on record
Our deepest sympathy goes to Lady Parsons in her
bereavement
GOSTA FORSSELL, MD
Professor Carl Gustaf (Gosta) Abrahamsson Forssell
the eminent Swedish radiologist, died in Stockholm on
November 13, 1950, in his 75th year He was bom at
Aspcboda Sweden, and educated at Upsala and at the
Karohnska Institute, Stockholm where he qualified in
medicine in 1906 He proceeded M D in 1913 From
1906 to 1908 Forssell directed the institute of surgical
radiology at the Serafimerlasarettet Stockholm In 1908
he took charge of the central radiological institute and was
chief phjsician at Radiumhemmet from 1910 to 1926 He
held the chair of medical radiology at the Karohnska Insti
tute from 1916 to 1926, becoming professor ordinarins
in that year In 1936 he was appointed professor of
diagnostic radiology a post which he held until 1941
when he became professor emeritus Forssell s early pub
lications were principally on the radiological anatomy
of the alimentary tract, but his later work on the radio
therapy of cancer earned for him an international repu
tation The Stockholm method of radium treatment
of uterine cancer, as carried out at Radiumhemmet vras
also devised by him Forssell published upwards of
200 papers and was the founder of Acta Radiotogica
which he edited from its commencement in 1921 until
his death In 1928 he presided at the second Inter-
national Congress of Radiology at Stockholm On the
occasion of his 65th birthday a fund of 100 000 kronor
svas placed at his disposal for research — the Gosta
Forssell Research Fund He was the recipient of many
honours both at home and abroad in 1939 he was
elected a foreign corresponding member of the B M A
and as recently as July last he was elected to the hono
rary fellowship of the Roval Societv of Medicine
We record with regret that Surgeon Lieutenant D A
Knock RN was killed in action in Korea towards the
end of last year Douglas Alexander Knock studied mcdi
cine at the London Hospital graduating MB B S in 1945
After holding appointments as house physician and clinical
assistant at the London Hospital and house physician at
the Southend General Hospital he joined the Royal Naval
Volunteer Rescrae Early in 1949 he obtained a permanent
commission m the Rosal Navy He met his death when
attached to the 41 Independent Commando Royal Marines
during operations with United Nations forces in North
easicrn Korea
J N H J wntes 1 first met Dougcie Knock dunng
the war when-hc was working as a student houseman at a
buss hospital in the South of England Although still
a student he was one of the mainstays during those diffi
cult times accepting with good cheer and performing with
surpnsingls mature abilits any task howeser new to him
He was soon a \cr\ competent anaesthetist and would have
done well had he remained in this specialts I came to
know him well when he was a house phssician He had an
inlense sense of duts a deep respect for his patient as a
person and a great sense of humour WTien he joined the
R N \ R his letiers were a source of endless amusement
because he was so well able to appreciate the ridiculous
elcmeni in all life s actisities After demobilization he was
restless and not the gas fnend he had been and soon we
heard that he had re.unied to the Navs I am sure none
of his friends were surpnsed to hear that he ssas in Korea
with a commando unit of the Mannes and it was with them
that he lost his life It is a tragic loss to his friends and to
medicine and I feel sure that there is a story of quiet
gallantry behind this announcement that may remain tin
sung Douggic was a most loyal friend who made
people sery happy He leaves us however some Very
cherished memories and although m\ son will miss his
godfathers more tangible gifts I shall be very proud to
tell him about Dougcie in later years.
Medico-Legal
THE INSANTTV DEFENCE IN DIVORCE
[From Oor Medico Legal CoRREsroNOENT]
A wife went out for the evening leaving her husband with
their young daughter She returned to find the room barn
caded the girl strangled and the husband recovenng from
the effects of an unsuccessful attempt to gas himself He
was tried for murder found guilty but insane and sent to
Broadmoor In a statement to the police made on the day
after the crime he said that he had planned it weeks ahead ,
he was afflicted with creeping paralysis due to a bad habit
continued from childhood and had transmitted this disease
to his daughter and so had decided to kill her and himself
In rational letters wntten from pnson he expressed great '
contntion for the grief he had caused to his wife and parents
He IS not incurably insane and may in the future be released
The wife petitioned for divorce on the ground of cruelty
and the husband by his guardian ad litem entered the
defence that at the material time he knew neither the nature
nor the quality of his acts nor that they were wrong and
was not responsible for them.
Mr Justice Pearce was thus faced' with the hitherto un
solved problem of whether insanity is a good defence against
a charge of cruelly in a divorce petition Apart from the
insanity the wife had an unanswerable case There can be
no greater cruelty to a woman than the killing of her child
and she had suffered very serious injury to her health and
nerves and would derive mental relief from dissolution of
the marriage
The reports contain quite a number of cases dealing with
the point but none is conclusive Courts have not agreed
on whether intention is a necessary ingredient of the matri
momal offence of cruelty and in any event no court has
ever found the insanity to have been of such a degree as
to negative intention The matter is complicated by the
question whether the M Naghten test applicable to crime
should be used in cruelty cases also A person accused of
crime who seeks to escape responsibility on the ground of
insanity must prove either that he did not know the nature
and quality of his act or that he did not know that it was
wrong
Mr Justice Pearce remarked that in criminal matters
where the object is punishment such a defence is obvi
ouslv necessary in a just society but it is not a safe analogs
to assume that justice requires it in matnmonial matters
Here the duly of the court to interfere is intended not to
punish the husband but to protect the wife and so the
question it has to decide is whether the wife could with
safety to life and health live wath the husband now To
withdraw from the ambit of legal cruelty conduct that is
intolerable but due to insanity would make the court power-
less to help in cases where help mav be most needed
Thcoreticallv to include it might also cause hardship ' but
since the wife has presumably been unable to tolerate the
mamage tie.and has wished for divorce the husband would
be unlilelv to attain happiness by maintaining ihe tie
Moreover since such a defence has in no reported instance
ever been made out on the facts its existence would not be
of much practical benefit The judge therefore held that
'tiKeck V Lissael 19'0 2 All E R., 233
144 Jan 20, 1951
MEDICO LEGAL
British
Medical Journal
the insanity defence was not open to the husband and
granted a decree to the wife, both because he could not
find that insanity has ever been clearly established as a
defence to a petition based on cruelty and because such
a defence does not in his opinion accord with the true view
of the law relating to cruelty
However in case his view of the law should be reversed
on appeal, Mr Justice Pearce dealt with the question
whether the husband had proved the degree of insanity
necessarj to establish absence of responsibility He con
sidered that the second part of the M Naghten test, whether
or not the husband knew that he was doing wrong, was very
unsatisfactory in measuring misdeeds so dependent on the,
circumstances and personalities of the parties as acts of
cruelty Things may be cruel m particular circumstances
and between particular persons that are not at the time of
their commission known to be wrong The Court of Appeal
has ruled out the substitution of the word cruel for the
word wrong in the M Naghten test a ruling >vhich in
Itself IS further evidence of how unsatisfactory such a test
IS In cjvil matters the courts both of common'law and of
equity apply the first part of the M Naghten test, whether
the person alleged to be of unsound mind knew the nature
of the act This the judge thought would be reasonable
In the present case it was agreed that the husband knew
the nature and quality of his acts Moreover even if the
knowledge of wrong properly forms part of the test the
husband had not proved clearly, or at all, that he did not
'know that his acts were wrong and, as his conduct would
nave been unlawful even if the delusions had been true, he
could not escape liability for it Therefore even if the
M Naghten test is fully applicable to such cases — which in
the judges opinion it is not — the result would still be the
same and the wife would obtain her decree
Universities and Colleges
UNIVERSITY OF OXFORD
In a Congregation held on November 18 1950, the degree of
D M was conferred on D S Parsons
The following medical degrees were conferred on December 16
1950
D M — J F Monk J C Pease
B M — J P Single M J V Bull, G P Burn *I B Denny,
B S Freeman J R Goldmg, W D E Hamilton, *R H HiU
D E Hone Ruth Lister J G Millar, C G Miller H E
Milligan R G Mitchell R M Moms Owen, E F H Murphy
J K Pearce Constance M Ridiey Jane M Robinson, Gillian
Rowe Dutton G M Scott, *Barbara Sellman Jean McI Smellic,
G T Smerdon Mrs Diane L Spencer J G Wallace
Professor A D Gardner DM FRCP FRCS and
Professor E G T Liddell DM F R S have been appomted
chairman and Mce chairman respectively of the Faculty of
Medicine and Professor W E Lc Gros Clark DSc, FRCS
F R S , chairman of the Faculty of Biological Saenccs for the
academic >ear 1950-1
Applications for the Horatio Symonds Studentship in Surgery
for 1951, of the value of about £200 a year must reach the
Registrar of the UniNcrsity Clarendon Building Oxford by
March 31
N Rosen (Rounfihay School) has been elected to a War
Memorial Medical Scholarship at Umversity College Oxford
♦In absence
UNIVERSITY OF ST ANDREWS
William Leslie Burgess C B E M D F Jl C P Ed has been
appointed to the newl> instituted James Mackenzie Chair of
Public Health and Social Medicine in the Unnersity from
April 10 Dr Burgess was appointed assistant medical officer
of health for Dundee m 1913 becoming medical officer of health
for the at> fi\e vears later Since 1918 he has been a member
of the stair of the UniNcrsity of St Andrews first as lecturer m
public health and in fc\crs and later as reader in public health
Dr Burgess has aUo served on man> departmental and inter
d partmcnial committees of inquiry
' UNIVERSITY OF LONDON
Thc’^following candidates have been approved at the examinations
indicated
M D — Branch I (Medicine) D M Abelson M Atkinson
A G Beam G A Bedwell J D Blarney, S O Boldy, L
Brotmacher F G Campbell H E Claremont R S C Couch,
J S Crowther, L Cudkowicz, A E Doyle C J Earl, T R L
Finnegan, P Freedman C N Grainger P C Hams (Mark of
Distinction and University Medal) A R Hamson A Hollman
G Howells P E Jackson C L Joiner D A Kok, M J Livera
J Luder J C Macaulay R A Moir, C D Routh B Schwartz
L G Scott L V Sthyr P P Turner A Venner, R L Ward
R G Welch Joan C Wells R R Willcox I Yentis Branch II
(Pathology) Naomi Datta, Deborah Domach C H Gray (Mark
of Pistinction and University Medal), W J Hanbury A B Hitl*
G R F Hilson, J D O D Lavertme G L Le Bouvier, A J M
Reese R B H Tierney Branch III (Psychological Medicine)
A J P Oldham Branch IV (Midwifery and Diseases of
Women) J G Dumoubn D W James J C S Leverton
Branch V (Hygiene) D J Davies RAG Smith
M S — Branch I (Surgery) A Elton, T W Rowntree
The following candidates at the London School of Hygiene
and Tropical Medicine have been approved at the examination
indicated
Academic Postgraduate Certificate in Public Health —
Lily G Arumugam, IC M Basu, Ji P Brazil Carol W Buck
D H D Burbndge C G Burges^ T W Carnck C S Chou,
M J Colbourne A H R Coombes, J D Cottrell D E
Culhngton, G M Curtois R G Davies LEA Dearberg
M Doraisingham H El iNagar, A G Farr, M A Fawkes
L V R Fernando, P S Fuller A Girby, Y G Gupte
Margaret I Hendne P R Henson F R T Hollins J G S
Holman, I J Jeffery W H Jeffrey, E F E Kellar E H Lamb
N Leitch r M Maegregor, D H Mackay G P Merson, G A
Mott, See Yook Ng G A R Perera R Perumal, W D
Ratnavale F G Sembeguya E S Sidey L Silverstone G A
Steele, Julie S Suleiman, Shwe Thwin, T Visuvalingam A S
Wallace i
UNIVERSITY OF. MANCHESTER
The Council of the Umversity has approved regulations for the
award of the Alfred Lucas Blam Memorial Scholarship in
Pharmacy established under the will of the late Mrs M E Blam
for the encouragement of research m pharmacy and allied
subjects The first offer wiU be made in September
UNIVERSITY OF LIVERPOOL
The following candidates have been approved at the examinations
indicated
M D — J W L Edwards, Elizabeth Rees
M Ch Orth — J Blockey, L Bonnm V K Drennan, K S
Fan L Henry, J H Hicks T MeSweeney F Machanik, J B
Maloney M R Reddy, A M Sallam, H O Williams
Final M B Ch B — Part III (Old Regulations) G M Barnes
Monica T Barry, Winifred Billmgton, Cynthia J Bladon,
Elizabeth J Coope H S Evans T K Hardy D H Jones
Mary W Malone Eileen P O Mahony C W R Pyne H
Shecter Sheila M Ward Marjorie J Williamson Passed in
separate subjects J C Holden (Medicine and Surgery)
D P H — Part I B Devhn M Doherty, G Fairclough
Wilhelmina N Gaye W A Glynn B Hamilton H M Thomas
J Vignoles
Certificate in Public Health — P J Burke Alta F Stout
NATIONAL UNIVERSITY OF IRELAND
The followmg candidates at University College Galway have
been approved at the examinations indicated
MB BCh B AO— Mary E Doyle J M Fahy, J F
Finnegan A K Forde B J Foy Sarah L Gavigan J J
HoHoway P K Joyce D Kelleher J V Loughlin C Lydon
Catherine M McDermott K U Moran ^ Cecily M Moms
P J O Hara Maeve T Treacy G P Walsh
QUEEN S UNIVERSITY OF BELFAST
The followmg degrees and diplomas were conferred on
December 20 1950
MD — R D N Blair B MullaUy B Blewett
MB B Ch B a O — C G Alexander S A Agnew
Elizabeth F Bennett J B Bowden W A Bojd C F Brennan
T D Brown J M R Campbell Janet C Davidson P J Devlin
D A Elliott N P Ellison Patriaa E Ferguson A G Fullerton
W J Glover F Hillman S R A Hogg T Horner D W
Ingram D H Johnston A Jones Dorothea Kelso Mea W
Jan 20, 1951
UNIVERSITIES AND COLLEGES
Pwnm
Mo CM. JOVUMAl
145
Kelso W J Kemohan Frances E W Kinnaird A L Kirkland
H Koreniager R S Lindsay Doreen E Linlon C R Locker
J C H Loughridge M J Lyons W T E McCaughe) E
McFall M J McKenna Ediih M McKinney A G McKnighr
Frances M McQuilty W N McWiniam R G S Malone V J
Marmion J E H Mercer N G Metruslry H A Millar, G
Moles M H Moles S Moore J F O Sullivan G C Patterson
J N Patterson ACC Pinion Norah I Rottgcr J L Russell
I McC Todd Mary Upnchard W G Wade J A kVeaver C R
Whiifield J S Willman, Sheila M Wilson H G Wright Sandra
Wyhe
C P H — A C Darrah R Logan F V Maclaine S H Moore
P N Newsam W T Orton W J Patterson 1 Simpson E M
Wells
royal FACULTY OF Pm SICIANS AND SURGEONS OF
GLASGOW
Professor L S P Davidson will dtlivcr the Finlayson Memorial
Lecture in the Hal! of the Faculty (242 St Vincent Street
Glasgow) on Wednesday January 24 at 5 p m His subject is
The Malabsorption Syndrome All medical practitioners arc
mvited to attend the lecture
ROYAL COLLEGE OF OBSTETRtCfANS AND
G1 NAECOLOGISTS
Ar a icccnt meeting of the Council of the College with the
President Professor Hilda Lloyd in the chair Mr Geoffrey
Kesnes and Dr R J Minnitt were formally admitted to the
Fellowship of the College
The President ms appoinied to represent the College at the
fifth Centenary Celebrations of the University of Glasgow
Lcvcrhulme Scholarships is re awirded to L W Cox MB
FRCS MRCOG J C MrClure Browne MB BS
MR COG and D C A Bevn MB Ch B MRCOG
The following candidates from Australia and New Zealand were
elected lo*the Membership Lois E Benson A D Byrne M
Connaughton E W Duncan J M Farrar F G Favaloro R C
Gordon A M B Grant G H Green W R D Giaffiihs A L
Hellesirand R E Hemsiey T O Hollywood W G Jasper
A R Long R H Macdonald Flla A N Macknight LOS
Poidcvin N H W Sasby J R Sherwan W L Sloss K F
Tarlinion H R Thomson Helen C Thomson T W Vorrath
Marjone R Walker Alice Whcildon
The following candidates from New Zealand were awarded the
Diploma in Obsieines T J Oust Icy R R Grigor R G
Gudex G C Liggms Diana Monuomery, R A Warren
FACULTY OF RADIOLOGISTS
The following candidates base saiKiicd the Fellowship Board at
the IdSO examination for ihc Fellowship Radmtheran D G
Braihenon B A Sioll R C Tudway Radiodiagnosn A N
Gaballa W S Holden O B Lode
3
EProCMrOLOGICAL ^OTES
Smallpox at Brighton
Up to noon on January 16 Ihcrv have been 30 cases of
smallpox in the Brighton area Light cases have died The
cases have come from three mam foci
(1) Bt\fndean ffoipimf — All the initial cases from here
were employed m the ward in which the second case was
nursed for 10 daw Eight hclonced to the dav or night
nursing staffs and two were ward maids Of ihcse three
nurses and the two domestic workers have died During
the past few days four other cases have occurred in the
hospital These were connected more or less directly with
the personnel in the affected v.ard
(21 LaiirJn —The cloihinc of the original case veas sent
here and from this six employ ccs have contracted the disease
Two laundry workers have died
IT) Telephone Ctr/mnee— The second case was cmploved
here and two further cases have come from this source
In Ihe past week f ur cases have tsecn no iffed not directlv
related to the thre- mam foa they were not under survcit
lance when Ihev developed' the disease Rather tenuous
circumstances mav relate these cases to existing foci but
the position is nor clear Olher cases o*' this tspe hasc to
be exp'Cted The infection disseminated from th' three foci
before sinci survcii!an“c was set up is onU now becomme
manifest
Although the disease is confined to Ihe Brighton area and
there is no sign of spread to other parts of the United King
dom the stiaciesl vigilance is still imperative throughout
the country
Influenia
The statistics given below indicate an increased incidence
of influenza throughout England and Wales In the week
ending January 6 there were large increases m pneumonia
cases and deaths both in England and Wales and m the_
great towns while there was also a considerable increase
in influenza deaths in the latter — from 102 in the preceding
week to 458 in the week referred to here
This sleep rise reflects an unusually high prevalence of
the disease which may continue during coming vvecks Of
these deaths 339 out of the 45g occurred north of a line
roughly drawn from Crewe through Sheffield to Ihc Humber
and were largely associated with outbreaks on Merseyside
and Tyneside here the disease was generally mild in form
though highly infectious and the deaths with few excep
tions were among elderly people
There was also an increase in influenza deaths in the
London and South east Region compared with the preceding
week while increases of some degree occurred in all regions
It would appear that particularly in the north and north
west there is some increase in Ihc seventy of Ihe disease
The evidence of the numbers of new claims to sickness
benefits also indicates an increased influenza prevalence
especially in Ihe north and north west In these two regions
combined such claims totalled 74 844 in the week ending
January 2 compared with 31 371 in the week ending
December 19 1950 For the whole country the claims
nearly doubled themselves in the same period
It would appear that m the areas in the north and north
west originally attacked Ihe epidemic has passed its peak
But there is evidence of an increased prevalence in various
towns and cities not so far seriously affected — for example
Manchester Bolton Salford Wolverhamplon Sheffield
Norwich — and possibly this indicates a spread of the
northern epidemic Similarly in Carlisle (Cumberland)
and Kendall (Westmorland) there were suggestive rises in
insurance claims
In the Southern Eastern and Western Regions there is
an increasing general prevalence of influenza in many areas
with scattered localized outbreaks here and there but
nowhere so far as is known at present do situations exist
similar to those of the past fortnight in many cities and
towns in Ihc north west During Ihe week ending January 6
deaths certified as due to influenza in London county
numbered 40 This docs not suggest or even portend
epidemic proportions
The position in Ihe south up to Jantiarv J6 remains un
certain But there was serological evidence of virus A
infections and virus A wias isolated from garglings in one
cave durinc Ihe week ending janiian 13
The following cases of and deaths from pneumonia and
influenza have been reported in the great towns
4 \\
ii>n
IB'Jl Z5‘U
iW’l
j9/l2'
16
73 iz'sojizi
6/1
Pneuttenja
! zsy
^61
3»3
302
1
1
1 1
347 J
374
l3«
j vm
Deaihj
• 19S
m
in
07 (
1 193
ZJS 1
: 35t
1 3S3
DO
In^4cn?a
Dcati:*
1 .9
t :o
1 *** f
24 1
; 7s|
i »1
33
! 54 ■
i
j joa
45S
Totals from ibe first wc-k of the scar in the great towns
compared with the preceding two years are as follows
1 ITv’ I 19'a I 1951
146 Jan 20, 1951
EPIDEMIOLOGY SECTION
BjtmsH
Medical Journal
Thd following Table shows notifications of pneumonia
— primary and influenzal — in England and Wales-
4/11
11/11
18/11
1 25/11
I2/I2
9/12
16/12
23/12
1
,30/12
6/1
Pneumonia
433
465
558
490
1 497
573 1
684
647
962
1774
Corresponding
week 1949
419
534
667
1 710
1 1
715 ,
734
1
1
676
634 1
1
84Z
1
1 120
The following weekly claims have been made on the
Ministry of National Insurance Week ending October 31
1950 127,245 November 7 144446, November 14,
148 497, November 21, 147,415, November 28, 145 783,
December 5 142 011 , December 12, 141 403 December 19,
128 842 December 26 87,277 (four days only) January 2
1951, 246 223
Regional totals of influenzal deaths in the great towns
in the week ending January 6, and rates per million (in
parentheses) were Northern 103 (83) Eastern 9 (119),
East and West Ridings 6 (2 6) London and South east 76
(10 8) Northwestern 230 (63 7) Southern 4 (4 9) North
Midland 8 (7 6) Wales 3 (4 5) Midland 11 (4 8) South'
western 8 (8 3)
Influenza deaths in the great towns by age groups were
Under 1 2 1-14 1 15-54 58 55 and over, 357 Deaths
in London Administrative County — 40 — are not included in
this age grouping
Influenza Abroad
There is news of an extensive outbreak of influenza in
Belgium It IS said to be mild in type with a low mortality
No virus has yet been identified In Holland influenza is
also prevalent and there is evidence that it is due to virus A
possibly of the A pnrae type of the Swedish outbreak
Denmark is apparently still suffering from a high preva
lence and it is reported that there is a heavy epidemic m
Greenland with an attack rate of about 90% The disease
is probably prevalent in northern Spain but information at
present is indefinite
Poliomyelitis
Notifications of poliomvelitis in the week ending
January 6 were paralytic, 37 (36) non paralytic 10
(17) total 47 (53) Figures for the previous week arc
given in parentheses Notifications in the corresponding
week of the previous four years were 1947 10 1948
58 , 1949 20 1950 54 The notifications in the first week
of 1951 are therefore little different from those of the
corresponding week in 1948 and 1950 Each of these three
years are comparable in that they followed years of high
incidences of the disease ,
The Inumber of notifications of acute poliomyelitis (not
corrected for revision of diagnosis) in England and Wales in
the second half of 1947 1949 and 1950 are shown in the
following Graph (reproduced from the Registrar General s
If'eef.ly Return for England and Wales 1950 No 52)
Notifiable Diseases in 1950
The chief features of the returns of notifiable diseases in
Encland and Wales dunng the year were the very high inci
dencvs of whooping cough acute poliomyelitis and dysen
ten The trend of whooping cough was notable for the
high level in the last weeks of the year when the notifica
tions were the largest ever recorded for this season There
IS some doubt whether the increase in the number of notifi
cations represents a real increase iri the incidence of whoop
ing cough Possibly more cases of whooping cough are
seen by medical practitioners since the operation of the
Health' Service
The trend of the notifications of acute pohomyelitis in
1950 differed from that recorded in 1947 the rise began
earlier and fell more slowly from a smaller peak in 1950
than in 1947 (see Graph below). The total notifications of
measles is not exceptionally high because of the low level
in the beginning of the year but the number of notifica
tions in the second half of the year was larger than ever
recorded for any third and fourth quarter The incidence
nf dysentery was high throughout the year the number of
notifications ranged from 149 to 461 per week during the
first quarter, from 213 to 457 in the second quarter, from
137 to 278 m the third quarter and from 169 to 1,214 in the
fourth quarter
A further substantial fall in the number of notifications
of diphthena was recorded in 1950 but the rate of decline
IS falling For 1948, 1949 and 1950 the number of notifica
tions was 75, 62 and 58% of the number recorded in the
preceding year A companson of the records of 1950 with
recent years is made in the Table below
Cases IQ England and3^ales
1946
1947
1948
1949
'1950
Scarlet fever
SVhooping cough
Diphthena
Measles
Acute pneumonia
Memngo''occal tofections
Acute poliomyelitis
Dysentery
Eotenc (typhoid and para
typhoid fevers)
57 614
92 028
18 156
154 826
36 106
2 627
703
8441
I 367
60 524
94 241
10 528
399 461
34 348
3 147
9 251
4 179
880
75 460
145 878
7 903
396 841
31096
1 971
2 175
5 587
873
71 753
102 516
4 929
384 361
34 624
1 5S6
6 850
4 819
1 I3S
66 852
157 714
2 858
366116
30 7M
1 745
8 699
18 135
654
Deaths m the 126 Great
Towns
Tuberculosis
•
•
11 715
10 877
8 934
2 629
1723
608
3 090
1 859
Acute poliomyelitis
•
•
139
415
501
Whooping cough
443
522
434
329
250
Diphthena
258
130
100
51
27
• Not avatJaWe
Infectious Diseases
Dunng the week ending December 30 1950, large nses
were recorded in the' number of notifications of measles
3 140 and acute pneumonia 315 while a decrease of 333 was
reported for dysentery The largest nses in the incidence
of measles were 632 in Lancashire and 366 in London The
number of cases of acute 'poliomyehtis notified was the
same as in the preceding week , the largest returns were
4 in the counties of Devon, Lancashire, and Warwick
Dysentery
The largest returns for dysentery in the week ending
December 30 1950 were Lancashire 120 (Southport C B
29 Middleton M B 24, Liverpool C B 15
Oldham CB 12) Leicestershire 119 (Leices
ter CB 93) Yorkshire West Riding 69
(Earby U D 14) London 44 (Finsbury 9,
Paddington 8), Essex 26 (Romford M B 19)
Shropshire 26 (Shrewsbury MB 11) Glam
organshire 24 (Swansea C B 20) Stafford
shire 24 (Stoke on Trent C B 13), Cheshire
23 (Wallasey C B 10) Sussex 21 (Eastbourne
C B 17) Middlesex 21 (Edmonton M B 8),
Surrey 19 (Croydon C B 13), Durham 16
Northants 15 (Kettenng M B 14), Devon
shire 13 Cumberland 12, Southampton 11,
Warwickshire II
Week Ending January 6
The notifications of infectious diseases in England and
Wales dunng the week included scarlet fever 923 whoop
ing cough 5 009 diphtheria 38 measles 21 688 acute pneu
monia 1 774 acute poliomyelitis 47 dysentery 834 smallpox
13 paratyphoid fever 1 typhoid fever 4 In the great towns
the deaths attnbuted to influenza numbered 458
1 700
5 600
^ 500
I 400
£ 300
£ 200
S 100
g 0
K
—
—
— 1 — 1 — 1 —
POLIOMYELITIS
Ri
m
BB
Hj
■1
m
m
■
IBI
IB
Hi
lull
■
■
s
■1
Hi
IS
8i
B
Hi
Bi
ws
m
Hi
B
S
s
B
SB
B
B
B
V/EEK NUMBER
5?
JaS 20, 1951
EPIDEMIOLOGY SECTION
RKJTttn
MtDICAL JOtTLVxL
147
No ^2
iNrrcnous diseases and wal STATisncs
\Vc pnni below a Sumrrary of Infecliou Di^ascs and Vital
Statistics in the British Isles dunne the v\cet ended December 30
Figures of Pnncipal Notifiable Disease forihe»eek and those for the corfc-
iponding Week, last year for (a) Enplant and \Va1 s (London included) fb)
e - (d)rire (cl Northern Ireland
rece dfd under each Infect cut
rgl nd and N\a1es (Including
■ (clThc 16 principal tossn* m
(e) The 10 principal tomns In
Northern Ireland
A dash ^ denotes no cases a blank s'^ace d notes disease not notifiable or
no return available
Medical Novs
Medals for Blood Donors
The Minjslr> of Health announces that awards arc to be
presented to long service donors m the National Blood
Transfusion Service the Scottu^h National Blood Tnnsfusion
Assocnlion and the Greater London Red Cross Blood
Transfusion Service and to other donors who have given
repeated gifts of their blood To qualifj a volunteer must
Disease
1950
|l947 (Corresponding^ eeV)
1 (a) 1
(b)
1 (c)
( ^
(el 1
(O
(b)
(c)
(d)
(e)
tions of blood since Septem **
ber 1939 Women donors
will receive a brooch and jf Z ^
men a lapel badge The f
design of the award which j ^ ^ 3 ^ / 'jj
has bccil personally ap L ^ v ^ '
proved by His Majesty the L 1 ^ 1
King shows two interlock \ /
ing hearts surmounted by \\ /
the Crown and resting on V ^ / /
a scarlet background There N
Meningococcal fnfcc
tion
Deaths
1
2
n
1 1
3
-
1
22
2 '
_2,1
-
-
\
Diphthena
Deaths
4ii
1 1,
3
n
1
—
102
1
10
1
1-
1
V .\
n \
Dysentery
Deaths
691
44'
104
1
j
5
197
1 9
1
113
K
1
Encephalitis acute
Deaths
7
—
*“
— .
1“
'
— '
1 1
7
Erssipclas j
Deaths
19
6
1
I
24
i ^
7
Infective enienils or '
diarrhoea under
2 yean
Deaths
26
1 1
10 7
( It '*
20
4
25
1
2
iward silver giU for at
least 50 donations silver for 25 donations and bronze for
10 donations There are now nearly 400 000 donors in the
Measles*
Deathst
17 468
Il92-
1
io-»
81
80
1 978
47
21
56
1
145
National Blood Transfusion Service and it is estimated
that about 200 donors will be entitled to the stiver gill award
Ophthalmia oeona
torum
Deaths
21
3
,0
-
28
3
5
>
-
SOOO lo the siher and 70000 to the bronze Anyone who
thmls he is entitled should apply on the special form obtain
able from the regional blood transfusion centre where he is
at present enrolled from a local organizer or at a blood
ParatjTihold fever
Deaths
6
I
—
z
2
z
1(B)
z
z
Pneumonia iniluen
zal
Deaths (from In
962
64
23
6
842
59
22
6
11
IntcmatjODal Research on Rheumatic Fctcr
nuenra)*
102
8
3
1
28
5
4
1
—
The American Council on Rheumatic Fever of
the
Pneumonia primary
Deaths
383
269
A
17
3II
^’1
362]
1 1
44
18
American Heart Association is co ordinaling an investiga
tion at 12 centres in Britain Canada and the USA in
Poliomyeiius acute
Deaths)
53
5
i ^
1 ^
—
66 '
81
1
1
1
3
1
which all patients with acute rheumatic fever treated with
ACTH or cortisone during 1951 will be followed for at
Puerperal foer
Deaths
1 i
—
least three ycirs lo sec whether these hormones actually
'll cr the course of the illness and prevent rheumatic heart
Puerperal pyretia t
Deaths
38
n
5
4
4
6
—
1
disease or whether they merely suppress symptoms Hic
makers of ACTH and cortisone have each given $5 000
Relapsing feser I
Deaths '
— :
i-i
1
1
—
towards the cost of organizing the co operative study and
arc providing the large amounts of the two substances
Scailct fcsxr
1 0*6
62
ISI
52'
4
2^27
1 159
255{
til
196
required In Britain the Medical Resenreh Council is
Dcaihst
I-I
— j
—
1
-1
—
—
financing the research in association with hospitals
at
Smallpot
Deaths
4
—
—
' Z
—
1 —
, —
—
1 —
Newcastle Cardiff Sheffield Taplow and I ondon which
arc undertaking the work In Cnnadi the Hospital for
TVpl'o d feser
Deaths
Z j
= 1
—
h
I
25
1 si
-1
-1
-1
I
Sick Children m Toronto is being helped by the Omdian
Rheumatism and Arthritis Foundation The National Heart
T>Thus feser
Deaths
|-|
i
i
—
—
-I
= 1
z
Institute of the UJ5 Public Health Servue is helping research
m New ^orl Boston Denver and Chicago and in addi
WTioo^mg-cough
Deaths
3 690
7
3*3
4
44*.
25
t OIS
n
34
II
60,
f
55
' 1
tion the Armed Forces Epidemiological Board and the
U S Air Force are supporting a studv at a A F base
in Wvominc
Deaths fO-1 year) |
277
29
20
^5
'1
j’i
17
Deaths (etc uding i
siillbithsl 1
Arrjal d_ath rate
(per 1 t>i0 per*
tonsil mg) j
,3J
1
1 1
1061
fS^
m]
196
13«
5.56lj
1
14 2
194^
, 1
12-0,
167
Actiologj of Rheumatoid ArthnUs
It will be recalled Nee British \fe'iica} Journal 19^0
] 799 and 826) that the Scrntific Advisory Committee of
List b nbs
Ar-ual rate per
1 (XXt prsoas
li 1 s
1 5-S
1
«411
169 !
; 4
1
1
j-o
”1
i
8*0 25«’
1 '
17-4 17 8
223
the Empire Rh-iimalism Council reccntlv earned out a
carcfiillv conlrol!'*d and statistically analv“scd invcstiption
into this problem and showed nol onlv that th'Tc is no good
evidence for nanv so-called environmental causes but that
the clinical pattern is of a svstcmic disca c and not of a
pure arthntis The full repon has row been publi'^hed as
a supp^cmnl to the Anrcis of the Rhenrve ic Diseases and
IS obtainabl* pnee 75 6d^ from this oFre,
Han cun Soactv of London
Sti r bs
Ra e per 1 000
to a1 b 'lbs (fV i
c J- n- s 1 INsmt
1 1
"1
i \t
1
: i
\
1
1
1
1
Measles is aa no ha'' t in ind and the it a~is a « tb n o'r an
a~pTV*“ati''S c~ y
+ D a b fnr-i — »ea 1-s a*»J v.ar t fr»xf f-' E“‘i: ird and Wain London
(t^— -v t 1 Or en • ) »4 1 r be p '' vh-d
• l-wlji pn— a-y f->e— j f-.* Lng a-id and Waicr Lenioa (a-rviss^ ire
J Th of «5,a •vs v>r“ve t a*»d po i3
Erg i*si a*vd W ai*v. (»--i - era i^r c-nr* y) are cc*xi*-.r»w
J t*>-l,KSn po'^^'a <’f»— ^£> Ejv * 1 ^ ar- W aW aod Eire
^ Pnnarv p-irr— ro 1 if-*'- e tn E-'t.
i for
Th- Bu-hstop Browre Pnzi for 19'0 has been award'd to
C. J Gave, for his essay on The Maragent'M o' t'-'
Hcpeloss Ca'c "
148 Jan 20, 1951
MEDICAL NEWS
Bvtob *
Medical Joumul
Ministry of Food Announcement
After February 28 national dried milk will no longer be
available to patients suffering from steatorrhoea coeliac
disease and tropical sprue From that date ^t will nor
maily be reserved for children under 2 years old to whom
It IS supplied as an alternative to liquid milk The Ministry
will, however consider granting supplies of national dried
milk to children over 2 years of age or to expectant mothers
if they present appropriate medical certificates
St John Ambulance Bngnde
Mr Frank H Edwards of Shrewsbury has been appointed
Surgeon in Chief in succession to Dr Corbet Fletcher of
Hampstead, who has resigned Mr Edwards is consultant in
obstetrics and gynaecology to No 15 Hospital Group
(Shropshire) and to Shropshire and Montgomeryshire County
Councils Dr Marcus M Scott, of London, has been
appointed deputy surgeon in chief
English Patients for Norwegian Sanatoria
Dr Claude Lillingston writes from Bergen to point out
that, with a population of only 3 2 millions, Norway is now
provided with some 5,000 beds in sanatoria coast hospitals
and homes for the tuberculous and many beds are un
occupied and ready to receive patients from abroad at
charges which are moderate partly because the Norwegian
currency is soft Inquirers interested m the subject should
communicate with the medical superintendent Mesnalien
S'lnatonum Lillehammer Norway or the secretary general
of the Norwegian National Association against Tubercu
losis His address is Nasjonalforeningen mot Tuberkulose
Incogmtogate 1 Oslo Norway ^
Manchester Medical Society
At a meeting of the Section of Medicine on December 6
1950 Dr G G E Smyth gave a paper on ‘ A Re examina
tion from the Clinical Standpoint of some Aspects of Dis
seminated Sclerosis
In Brief
Dr H P Himsworth secretary of the Medical Research
Council is visiting West and East Afnca December 29-
February 11 to inspect vanous colonial research units con
cemed with virus diseases malaria leprosy and trypano
somiasis and hot climate physiology
Dr Chaloem Puranananda, secretary of the Thai Medical
Research Council and director of the Pasteur Institute Bang
kok who has been touring Western Europe^ is spending
three weeks in Bntain January 3-24 visiting medical re
search institutions and studying recent Bntish developments
in electron microscopy
COMING EVENTS
Association of Clinical Pathologists
The 45th scientific meeting of the Association of Clinical
Pathologists will be held in the Meyerstein Lecture Theatre,
Westminster Medical School Horseferry Road London
SW on Friday and Saturday January 26 and 27, at
9 30 a m and demonstrations will be given at the Royal
Army Medical College Millbank S W from 9am on
January 26 to 1 p m on January 27 A private business
meeting will be held on January 25
Contraceptive Technique
A lecture and demonstration (on living models) on contra
ccptive technique will be given by Mane C Slopes PhD
at the Mothers Clinic 108 Whitfield Street London W on
Thursday February 8 at 2 30 p m Tickets must be obtained
imadvance as space is limited
Neurology and Eve Diseases
Professor Torsten Sjogren of Stockholm will deliver a
lecture on Hereditary Neurologic Diseases Assoaated with
Certain Eve Diseases at the Institute of Neurology
National Hospital Queen Square London W C on Friday
March 9 at 5 p m
SOCIETIES AND LECTURES
A fee 15 charged or a ticket is required for attending lectures
marked ® Application should be made first to the institution
concerned
Monday
•Institute of Child Health Hospital for Sick Children Greai
Ormond Street London WC — ^January 22 5 pm The
Future of the Child Health Services by Professor W S Craig
Institute of Psychiatry Maudsley Hospital Denmark Hill
London S E —January 22, 5 30 p m lecture demonstration by
Dr E Stengel
Institute of Urology — (I) At St Paul s Hospital Endell Street
London W C January 22 1 1 30 a m Non gonococcal
Urethritis by Dr A H Harkness ,2pm Neoplasms of
the Urethra Penis and Scrotum by Mr D I Williams
(2) At St Peter s Hospital Henrietta Street London W C
3 30 p m ward round by Mr J G Sandrey 5pm, museum
demonstrations by Mr H K Vernon \
Medical Society of London II Chandos Street Cavendish
Square W — January 22 8 30 p m discussion Headache
to be introduced by Drs Macdonald Cnichley and R Bodlcy
Scott
Royal Eye Hospital St Georges Circus Southwark London
SE — ^January 22 4 pm Optics (Revision) by Mr H N
Reed
©Royal Eye Hospital St George s Circus Southwark London
S E — January 22 5 30 p m , Anatomy of the Eye and Orbit
by Professor T Nicol
Tuesday
British Postgraduate Medic ' School
of Hygiene and Tropical ^ ondon
W C January J23 5 30 pj- ep b\
Professor E D Adrian O ivi , i iv ^
•Institute of Dermatology Lisle Street Leicester Square
London W C — January 23 5 pm, Diseases of the Nail
by Dr D I Williams
Institute of Urology —At St Paul s Hospital EndcU Street
London WC, January 23 10 am Stress Incontinence in
Women by Mr Harland Rees 2 pm Diseases of the
Female Urethra by Mr H G Hanley 3 30 p m ward round
by Mr J E Semple 5pm Injuries Fistulae and Foreign
Bodies in the Urethra ^ Mr H G Hanley
Royal Eye Hospital St George s Circus Southwark, London
S E — ^January 23 5 pm, Mistakes and their Lessons by
Mr T M Tyrrell ^
Wednesday ''
©Empire Rheumatism Council — At 41 Portland Place London
W January 24 6 p m annual ceneral meeting
•Institute of Dermatology Lisle Street Leicester Square
London WC — January 24 5 pm Medical Mycology
lecture demonstration by Dr R W Riddell
Institute of Urology — At St Paul s Hospital Endell Street
London W C January 24 10 a m Epididymitis Cystic
Swellings of the Scrotum by Mr J D Fergusson 1 1 30 a m
Congenital Defects of Testis and Epididymis by Mr D I
Williams 2pm Congenital Defects of Kidney and Ureter
by Mr J G Sandrey 3 30 p m Calculus Disease of Kidney
and Ureter (1) by Mr H P Winsbury White 5 pm
Calculus Disease of Kidney and Ureter (2) by Mr H P
Winsbury White
Royal Eye Hospital St Georges Circus Southwark London
S E — ^January 24 5 p m Pseudoglwma by Mr R P Cnck
Royal Faculty of Physicians and Surgeons of Glasgow 242,
St Vincent Street Glasgow — January 24 5 pm The
Malabsorption Syndrome Fmlayson Memorial Lecture by
Professor L S P Davidson
Thursday
British Postgraduate Medical Federation — At London School
of Hygiene and Tropical Medicine Keppel Street London
W C January 25 5 30 p m Cutaneous Sensibility by
Dr A G M Weddell
Institute of Urology — (1) At St Paul s Hospital Endell Street
London W C January 25 10 a m Disturbances of Miciun
tion m Nervous Disease and Injurv by Mr A W Badenoch
11 30 a m , Incontinence in the Male Atony of the Bladder
Enuresis by Mr D T Williams (2) At St Peters Hospital
Henrietta Street London W C 3 30 p m ward round b)
Mr H K Vernon (3) At St Paul s Hospital Endell Street
London W C 5pm Tumours of the Testicle by
Mr H G Hanley
Liverpool Medical Institution 114 Mount Pleasant Liverpool
—January 25 8 p m Renal Cortical Necrosis by Dr H C
Moore
London Jewish Hospital Medical Society — At Medical Society
of London 11 Chandos Street London W January 25
3pm The Approach of the Forensic Pathologist to the
Investigation of a Case of Murder by Violence by Dr F E
Camps
Medico Legal Society — At 26 Portland Place London W
January 25 8 15 pm The CMC Hitherto and Henceforth
by Dr Robert Forbes \
Royal Eye Hospital Si George s Circus Southwark London
S E — ^January 25 5 p m Papilloedema by Dr S Nevin
Jan 20, 1951
MEDICAL NEWS
BMTTSn
Medical Journal
149
St AjfDREWs UNlvtRsiTY — At Lecture Theatre Matena Medtea
Department, Medical School Smalls Wynd Dundee January
25 5 pm The Influence of Adaptation on Host Parasite
Relationships in Disease by f^ofcNsor W J Tulloch ^
St Georges Hosphal Medical School Hyde ParL Comer
London S W — January 25 4 JO p m lecture-demonstration on
psychiatry
Torquay and Distthct Medical Society — At Torbay Hospital
January 25 8 JO p m Backache Sciatica ana Ruptured
Disks by Mr Kenneth Pndie
University College (Phvsiology Theatre) Gower Street London
we — ^January 25 5 la pm Physico-chemical Properties and
Pharmacological ActiMty of Drugs by Mr F Bergcl PhD
D Sc
Friday
Kent and Canterbury Hospital, Canterbury —January 26
5 p2n clmical meeting
London Unin'ersity — At London School of Hygiene and,
Tropical Medicine Kcppcl Street Gower Street W C
January 26 5 JO pm Infection and Immunity in Smallpox
special university lecture m pathology by Professor A W
Dowme
Medical Society for TirE Studt op Venereal Diseases 11
Chandos Street, London W — January 26 8 pm general
meeting
•Royal Eye Hospital St George s Circus Southwark London
SE — ^January 26 5 30 pm Physiology of the Eye
Royal Medical Society 7 Melbourne Place Edinburgh —
January 26 8 pm The Wide* Scope of Therapeutics
dissertation by Mr J K Stewart Kirkaldy
Royal Sanitary Institute — At Royal Technical College Salford
January 26 10 30 am papers The Promotion of Mental
Health fn the Community * by Dr A Tome and Professor
E W Andefson The Control of Infection in the Com
munity by Dr M T Parker and f^ofessor Wilfnd Gaisford
Temperature Control The Basic Principle of Food Hygiene
by Mr J C Starkey
Saturday
Biochemical Society — At Postgraduate Medical School Ducane
Road London W January 27 lOJO a m 293rd meeting
Papers will be read
British Association of Aucroists —At Royal Society of
Medicine 1 Wimpole Street London W January 27 Ham
annual general meeting 11 30 a m short papers will be read
Kent Paediatric Society— At Famborough Hospital Kent
January 27 2 30 p m clinical meeting
BIRTHS, MARRUGES, AND DEATHS
niRTIIS
Browne —On December 25 1950 ■( Ncwcuile-upon Tyne to Barbara
(formerly Cunningham) wife of Professor R C Browne DM M R C P
t daughter*— QIzabetb Caroline
Cantor —On January 9 1951 at the Mlddleiea Hospital London W to
Kathleen (formerly Wallach) wife of Dr J Cantor a »on— -TimoUiy
Jefferson
MARRIAGES
Abramaoo— Dods — On December 9 1950 at CoUnton Church Edinburgh
Allan William Abramson M R C P D C H to Morag Dods
M R C O G
DEATHS
Armstroos. — On December 30 1950 at 120 Glouccitcr Court Kew Surrey
Wilfred Erne t Arbuihnot Arm irong MRCS LRCP Lieutenant
Colonel IMS retired aged 85
CampbefL— On lanuary 3 1951 at Dundee Peter Campbell MB of
Scurbrae Balmcrino Fife aged 94
CU^ — On January I 1951 Aann Catherine Oark MB B Chlr DA
of 153 Cromwell Road London S W
DarlvTaylor — On December 29 1950 at 3 Spencer Road South, ea
Edward James Davis-Taylor MB B Chlr
Droocht — On December 31 1950 Roben Smerger Albert Drought MB
B Ch of Brabourne Bexbill-on Sea Suisea aged 79
Matson — On December 21 1950 at Melbourne Victoria Australia Thomas
Rhodes Matson DSO MB (Hi B late of 10 Albany Street
Edinburgh
Mitchell — On December 20 1950 Albert Waldegrave Mitchell MRCS
Slanc House Mjsdalcn Road Wand worth Common London SW
Munro —On December 25 1950 at Wlmboroe Dorset Marlorle Munro
(formerly Cu eden) MB (^ B Corner (pottage Lower Rowe near
Wimbome Dorset formerly of Romford Essex
Ormsby — On December 27- 1950 at Rochford Hospital Essex Wliflam
'' — 1 — » - D Co Mayo Eire late of
aged 78
Nursing Home Newport
riavenny Moo
I ell Peake M D of Reed
Thatch Burpham Arundel Su sex late of China
Platts — On December 18 1950 at 112 London Road Chelmsford Essex
Harry Platts MRCS LRCP
Rodeert — On December 30 1950 nt Ennerdale West Avenue Leeds
William Rodgers MB Ch B aged 79
Sansom — On January 6 1951 in a nursing home St Leonards Sussex
Charles Lane Sansom CMC FRCSEd DPH aged 88
Thomas. — On December 27 1950 at his home Wembley Middlesex Albert
Edward Thomas MD DPH
Ward —On December 20 1950 at New York City Gec^ge Gray Ward
M D
Warrlet — On December 21 1950 at 3 St German s Place Blackheatb
London S E Robert Waller Warrick MB B S
— On January 1 19^1 at his home Broadpark Moor Line Budlefgh
Saltertoo Devon Charles Ernest West F R C S aged 77
Any Questions?
Correspondents should give their names and addresses (not
for publication) and include all relexant details tn their
questions « Inch should be typed JFe publish here a selec
tion of those questions and answers v^hich seem to be of
general interest
Demon5trntion''of Malona Parasites
Q — What 15 the most certain method of demonstrating
malaria parasites in the blood of a patient suspected of
haxtng malaria^ When should blood films be taken ^ Is
the prior injection of adrenaline helpful^
A — Malana parasites can best be dcmonstrate(i in the
blood of a patient by making a thick film on a slide stain
ing the film with Giemsa s stain and examining it under
the microscope A good brand of stain should be used the
distilled water should be correctly buffered and the standard
technique of staining followed A prolonged search ma> be
necessary before a parasite is detected the film should be
examined by an expenenced worker and it should be con
firmed that the patient has recci^fcd no antimalaria treat
mcni The species of parasite may not be recognizable in
a thick film and can be more easily determined (if the
infection is not too light) in a thin film
As a rule parasites are present throughout the febnJe
periods they arc often most numerous in the case of
Plasmodium falciparum at the beginning of each paroxysm
In P malanar infections parasites may occasionally remain
undetectable for sbveral attacks and may appear only dunng
the later relapses so if this form of the disease is suspected
many blood films should be examined ^
Adrenaline as an aid to the diagnosis of malana is prob
ably more used by Conlincrtal than British worVeiB its
intravenous administration may cause a transient appear
ance of parasites in the peripheral circulation and this
procedure may therefore be helpful m doubtful cases
Treatment of Malaria
Q — (I) What IS the best treatment for BT and MT
malaria ^ (2) Is proguaml ( palitdnne ) still thought of
as highly as it wor txxo or three years ago^ (3) What is
the best way to prevent B T relapses ^
A — (I) Treatment of Bengn Tertian Malana (a) In an
indigenous population when the aim of treatment is simplj
to control the overt attack a single dose of 300 mg
proguanil^hydrochloridc 300 mg mepaerme hydrochlonde
or 500 mg chloroquine diphosphate usually suffices
Altcrrtaiivcly, full therapeutic courses may be given
proguaml (300 mg bd for 7-10 days) mepaenne (300 mg
tds for the first day 200 mg Ids for the second day
100 mg tds for 5-7 days) or chloroquine (500 mg on
admission 500 mg four hours later . 500 mg once daily
for the next three days)
(b) Tn individuals not frequently exposed to reinfection
and in whom it is desired to eradicate the infection treat
ment with paludrinc mepaenne or chloroquine will con
trol the overt attack but will not affect the relapse rate
Combined treaiVncnl with an 8 aminoquinoime such as
pamaquin and a schizontocidal drug will however, con
sidcrably reduce the relapse rate
Examples of such combined treatment are
1 Ouinine dihydrochlonde 10 gr (0 65 g)
Pamaquin hydrochlonde 10 mg
Given together tds for 10 days and
u Proguaml hydrochlonde 100 mg
“ Pamaquin hydrochlonde 10 mg \
Given together tds for 10 days
During treatment the patient must be kept in bed and
given pleifty of fluid Toxic effects from pamaquin arc
150 Jan 20 , 1951
ANY QUESTIONS?
BRmsH
Mnjicu. JouxjuL
most uncommon at this dosage but include acute abdominal
colic and cyanosis Renal complications may appear at
higher dosage
(2) Treatment of Malignant Tertian Malaria
Any of the following courses of treatment will bring about
clinical relief and possibly radical cure '
I Mepacnne hydrochloride 300 mg tds for 1 day
Proguanil hydrochloride 200 mg tds for 9 days
(The initial dose of mepacnne is introduced because of
the probability of the existence of proguanil resistant para
sites Where such resistance is not likely the mepacnne
may be omitted and the proguanil given for 10 days)
II Mepacnne hydrochloride 300 mg t d s foi 1 day
200 mg tds for 1 or 2 days
I , 100 mg tds for 7 days
'll! CMoroqume diphosphate 500 mg on adnussion
^ 500 mg 4 hours later
, 500 mg once daily for 3 days
The doses given above are for adults i
All active antimalarial drugs except pamaquin are well
tolerated by children The dosages for children are as
follows
1 Age
Birth to 2 years
3 to 5 years
6 to 10 years
11 to 15 years
Over 15 years
II Choroqume
Paliidrwe
25 mg tds
50 rag tds
75 mg tds
100 mg tds
adult dosage